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: Hyperglycemia is not typically a nonmotor symptom of Parkinson's disease. It is more commonly associated with metabolic conditions such as diabetes.
Choice B reason: Hypertension is not a nonmotor symptom specific to Parkinson's disease, although it can be present in many other conditions.
Choice C reason: Diarrhea is not commonly a nonmotor symptom of Parkinson's disease. Gastrointestinal symptoms like constipation are more prevalent.
Choice D reason: Depression is a recognized nonmotor symptom of Parkinson's disease. It can significantly affect the quality of life and is often underdiagnosed in these patients.
Correct Answer is D
Explanation
Choice A reason: Petechiae and bruising could be related to low platelet counts or clotting issues, but they are not directly indicated by the provided lab values.
Choice B reason: Jaundice and pruritus are symptoms associated with liver disease but are not specifically indicated by the lab values provided.
Choice C reason: Dyspnea and fatigue could be symptoms of many conditions, including liver disease, but they are not directly indicated by the lab values provided.
Choice D reason: Asterixis, a flapping tremor of the hands, and confusion are signs of hepatic encephalopathy, which can be associated with elevated serum ammonia levels, as indicated by the lab results.
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