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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
Choice A reason: A high-fat diet is not recommended for clients with chronic pancreatitis as it can exacerbate symptoms and lead to malabsorption issues.
Choice B reason: Checking blood glucose is important because chronic pancreatitis can affect the endocrine function of the pancreas, potentially leading to diabetes.
Choice C reason: While a semi-Fowler's position may be comfortable for some patients, it is not specifically an intervention for chronic pancreatitis.
Choice D reason: Assessing for hypotension is a general nursing intervention but not specific to the management of chronic pancreatitis.
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