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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A reason: The ABG results show an elevated pH and HCO3, which are indicative of metabolic alkalosis. The PaCO2 is within the normal range, suggesting that it is uncompensated.
Choice B reason: Respiratory acidosis would be indicated by an elevated PaCO2 and a decreased pH, which is not the case here.
Choice C reason: Metabolic acidosis would be indicated by a decreased pH and HCO3, which is not consistent with the given results.
Choice D reason: Respiratory alkalosis would be indicated by a decreased PaCO2 and an increased pH, which is not consistent with the given results.
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