The nurse is reviewing laboratory results for a client with sepsis. The results are as follows:

- WBC: 11,000/mm³ (normal range: 5,000-10,000 mm³)

- PaO2: 90 mm Hg (normal range: 80-100 mm Hg)

- aPTT: 50 seconds (normal range: 30-40 seconds)

- Platelet count: 98,000/mm³ (normal range: 150,000-400,000 mm³)

What is the nurse's priority action?

Assess for hematuria.

Monitor temperature.

Evaluate skin turgor.

Administer heparin.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.

Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.

Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.

Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.

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Correct Answer is D

Explanation

Choice A reason: The statement about the medication taking a few weeks to work fully is accurate and does not require follow-up.

Choice B reason: The statement that levothyroxine replaces the hormone the body used to produce is correct and reflects an understanding of the therapy.

Choice C reason: Acknowledging the possibility of lifelong medication is appropriate for levothyroxine therapy in the case of hypothyroidism.

Choice D reason: Levothyroxine should be taken on an empty stomach, typically 30 minutes to an hour before breakfast, to ensure proper absorption. This statement indicates a misunderstanding that requires nurse follow-up.

A. Evaluate pupil reactions every shift B. Assess temperature every 4 hours C. Monitor for cyanosis D. Check reflexes

Correct Answer is C

Explanation

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has been instructed about levothyroxine (Synthroid) therapy. Which statement by the client requires follow-up by the nurse?

Correct Answer is D

Explanation

The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Correct Answer is C

Explanation

A spouse expresses frustration when trying to communicate with a client with Parkinson's disease (PD). What can the nurse do to facilitate communication between the client and spouse?

The nurse is admitting a client with a thyroid disorder who presents with periorbital edema, cold intolerance, and weight gain. Which intervention should the nurse include in this client's plan of care?

When assessing a client with sepsis, which finding would be consistent with the late phase of septic shock?

The nurse recognizes that a patient with sepsis is at risk to develop hypotension. Which pathophysiological process is responsible for this symptom?

The nurse is planning discharge teaching for a client with Parkinson's disease. What information regarding levodopa/carbidopa therapy should the nurse include in this session?

The nurse is caring for a client with chronic pancreatitis. Which intervention is appropriate for this diagnosis?