When assessing a client with sepsis, which finding would be consistent with the late phase of septic shock?
Temperature 99.6°F
Skin flushed with capillary refill <3 seconds
Renal output 45 mL/hr
Arrhythmias
The Correct Answer is D
Choice A reason: A temperature of 99.6°F is a mild fever and not specifically indicative of the late phase of septic shock.
Choice B reason: Skin that is flushed with a capillary refill of less than 3 seconds does not suggest the late phase of septic shock, which would typically present with poor perfusion.
Choice C reason: A renal output of 45 mL/hr is within the normal range (0.5-1 mL/kg/hr for adults) and does not necessarily indicate the late phase of septic shock.
Choice D reason: Arrhythmias can be a sign of the late phase of septic shock as they indicate cardiac dysfunction, which is a result of decreased tissue perfusion and can lead to multiple organ failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An oral temperature of 99.8°F (37.7°C) post-operatively may not be unusual and does not necessarily indicate a complication.
Choice B reason: A post-operative hemoglobin of 10.9 g/dL is slightly below the normal range but may be expected after surgery due to blood loss.
Choice C reason: A client reporting a pressure sensation at the incision site could indicate bleeding or swelling under the incision, which can be a sign of a hematoma, a serious complication that needs immediate attention.
Choice D reason: Pain at the incision site is expected post-operatively and can be managed with pain relief measures.
Correct Answer is B
Explanation
Choice A reason: A soft diet with thin liquids may be recommended for patients with Parkinson's disease who have difficulty swallowing (dysphagia), but it is not the most appropriate intervention for all patients. Dysphagia is common in Parkinson's disease due to impaired muscle movement, and a soft diet can help prevent choking and aspiration.
Choice B reason: Assessing for orthostatic hypotension is crucial in the care of patients with Parkinson's disease. Orthostatic hypotension is a common non-motor symptom where there is a significant drop in blood pressure upon standing. Normal blood pressure should not drop more than 20 mm Hg systolic or 10 mm Hg diastolic within 2 to 5 minutes of standing². This condition can increase the risk of falls, which is a significant concern in this population.
Choice C reason: Exophthalmos, the bulging of the eyes, is not associated with Parkinson's disease. It is typically related to thyroid eye disease, such as Graves' disease, and would not be a relevant assessment for a Parkinson's patient unless there is a known co-existing thyroid condition.
Choice D reason: Limiting fluids to prevent urinary incontinence is not an appropriate intervention for Parkinson's disease. Adequate hydration is essential, and urinary incontinence should be managed with other strategies, such as bladder training, scheduled toileting, and possibly medication, depending on the cause.
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