Which client does the nurse identify as having the greatest risk for the development of sepsis?
A 59-year-old with rheumatoid arthritis.
A 71-year-old with a PICC line for TPN.
A 14-year-old with asthma and bronchitis.
A 39-year-old with renal calculi.
The Correct Answer is B
Choice A reason: While individuals with rheumatoid arthritis may have an increased risk of infection due to the disease itself or the use of immunosuppressive medications, it does not pose as high a risk as intravenous lines for sepsis.
Choice B reason: A peripherally inserted central catheter (PICC) line, especially when used for total parenteral nutrition (TPN), presents a significant risk for infection due to the direct access to the bloodstream, making this client at the highest risk for sepsis.
Choice C reason: Asthma and bronchitis can lead to respiratory infections, but these conditions do not typically result in sepsis unless the infection becomes severe and systemic.
Choice D reason: Renal calculi (kidney stones) can cause infections; however, they are less likely to lead to sepsis compared to a central line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason: While assessing temperature is important for monitoring infection, it is not the immediate priority in the treatment of UTI and sepsis.
Choice B reason: Monitoring urine output is crucial for a UTI but does not address the systemic infection that sepsis represents.
Choice C reason: Administering antibiotics is the most critical intervention for a client with sepsis due to a UTI, as it directly addresses the underlying infection and can be life-saving.
Choice D reason: Evaluating the current CBC is important for understanding the client's baseline and response to infection but is secondary to the administration of antibiotics.
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