The nurse is caring for an older adult who was admitted with a urinary tract infection and is now exhibiting signs of severe inflammatory response syndrome (SIRS). Which collaborative care goal(s) should the nurse include in the plan of care? Select all that apply.
Reduce white blood cell count.
Body temperature within normal limits.
Decrease blood pressure.
Negative urine culture.
Incision free of exudate.
Correct Answer : B,D,E
Choice A rationale: Reducing the white blood cell count is not a goal of SIRS treatment, as it would impair the immune system's ability to fight the infection.
Choice B rationale: Maintaining body temperature within normal limits is a collaborative goal to address the signs of SIRS.
Choice C rationale: Decreasing blood pressure is not typically a goal in the management of SIRS; the focus is on maintaining adequate perfusion.
Choice D rationale: Achieving a negative urine culture is a collaborative goal to address the underlying urinary tract infection.
Choice E rationale: incision free of exudate is an indicator of resolving infection and inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Placing an isolation cart outside the room is important, because mumps is a contagious viral infection that can be transmitted by respiratory droplets from coughing or sneezing. This intervention prevents the spread of infection and protects other clients and staff from exposure.
Choice B rationale: Instructing the child's parents about the need for transmission precautions is essential for preventing the spread of mumps to other individuals but the most important intervention is to place an isolation cart outside the room. Choice C rationale: Scheduling bedside playtime with the occupational therapist may be beneficial for the child but is not the most critical intervention in preventing transmission.
Choice D rationale: Assigning the child to a room close to the nurse's station may facilitate monitoring but does not directly address the prevention of transmission.
Correct Answer is D
Explanation
Choice A rationale: It is the role of the heathcare provider to provide the patient with explanation for the procedure and ensure their understanding.
Choice B rationale: Postponing the procedure may not be necessary if the client's concerns can be adequately addressed through communication and education. Choice C rationale: Calling the client's next of kin for verbal consent is not appropriate in this situation, as the client is capable of providing informed consent once concerns are addressed.
Choice D rationale: Notifying the healthcare provider isnecessary as it is their role to obtain informed consent. They should also address any patient specific concerns
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