Which assessment data for a client with a urinary tract infection and sepsis indicates the client may be developing a complication of sepsis?

Normal ranges for arterial blood gases (ABGs) are as follows:

- pH: 7.35-7.45

- PaO2: 75-100 mm Hg

Normal ranges for platelet count are:

- Platelets: 150,000-400,000/mm^3

ABG: pH 7.36 (normal range 7.35-7.45), PaO2 80 mm Hg (normal range 75-100 mm Hg)

Temperature 100.8°F

Platelets 99,000/mm^3 (normal range 150,000-400,000/mm^3)

Urine culture positive for gram-negative bacteria

Answer and Explanation

The Correct Answer is C

Choice A reason: The ABG values provided are within normal limits and do not indicate a complication of sepsis.

Choice B reason: A temperature of 100.8°F suggests an infection but is not specific enough to indicate a complication of sepsis.

Choice C reason: A platelet count of 99,000/mm3 is below the normal range and can indicate a complication of sepsis known as disseminated intravascular coagulation (DIC), which is a serious condition that can lead to severe bleeding or blood clots.

Choice D reason: A urine culture positive for gram-negative bacteria indicates an infection, which could be the source of sepsis, but it does not specifically indicate a complication of sepsis.

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Correct Answer is C

Explanation

Choice A reason: Encouraging ambulation is not a priority during a thyroid storm, as it can exacerbate symptoms.

Choice B reason: Sending a urine sample for culture is not related to the immediate management of thyroid storm.

Choice C reason: Monitoring temperature is crucial in the management of thyroid storm, as hyperthermia is a common and serious symptom.

Choice D reason: Administering levothyroxine during a thyroid storm would be contraindicated, as it could worsen the condition.

A. Monitor heart rate and rhythm. B. Auscultate lung fields and check blood pressure (BP). C. Assess for jugular venous distension (JVD). D. Check peripheral pulses.

Correct Answer is B

Explanation

Choice A reason: Monitoring heart rate and rhythm is important in heart failure management, but it does not directly reflect the effectiveness of enalapril and furosemide, which are primarily used to control blood pressure and reduce fluid overload, respectively.

Choice B reason: Auscultating lung fields can reveal the presence of fluid, indicating pulmonary edema, a common complication of left-sided heart failure. Checking BP is essential as enalapril is an ACE inhibitor that lowers BP, and furosemide can also affect BP through its diuretic effect.

Choice C reason: Assessing for JVD can indicate right-sided heart failure, which may develop secondary to left-sided heart failure. However, it is not the primary assessment for the effectiveness of enalapril and furosemide.

Choice D reason: Checking peripheral pulses is a general assessment and, while important, it does not specifically evaluate the effectiveness of the medications in question.

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Naxlex Comprehensive Predictor Exams

Which intervention would the nurse include when caring for a client experiencing thyroid storm?

Correct Answer is C

Explanation

A patient with left-sided heart failure is being treated with enalapril and furosemide. Which assessments should the nurse perform to evaluate the effectiveness of these medications?

Correct Answer is B

Explanation

The clinic nurse notes that a client with Parkinson's disease has been taking levodopa and carbidopa (Sinemet) for 10 years. Which assessment finding would indicate the client is experiencing a side effect of this medication?

The nurse is admitting a client diagnosed with a urinary tract infection (UTI) and sepsis. Which intervention would the nurse consider a priority?

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?

The nurse is caring for a client who has just returned to the unit following a thyroidectomy. Which assessment finding is a priority for the nurse to report to the healthcare provider?

Assessment of a client with cirrhosis reveals a distended abdomen, weight gain, and dyspnea. Based on this information, what interventions would the nurse include in this client's plan of care?

The nurse is interviewing a client with possible Graves' disease. Which response would the nurse expect when asking the client about her comfort in cold weather?

A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO2 39 mm Hg, HCO3 32 mEq/L. How would the nurse interpret these results? Normal values: pH: 7.35-7.45, PaCO2: 35-45 mm Hg, HCO3: 22-26 mEq/L

Which diagnostic studies will the nurse monitor for the client being treated for sepsis? Select all that apply.