Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)

Dry crust on the incision line

Adventitious breath sounds

Increased urine output

Decreased level of consciousness

Oral temperature of 38.3° C (101° F)

Answer and Explanation

Correct Answer : B,D,E

A.   Dry crust on the incision line may indicate normal healing, not necessarily infection.
B.   Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C.   Increased urine output is not a sign of infection but may suggest other issues.
D.   Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E.   Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.

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Correct Answer is C

Explanation

A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.

Correct Answer is ["94"]

Explanation

To answer this question, we need to use the formula: mL/hr = total volume (mL) / total time (hr). In this case, the total volume is 750 mL and the total time is 8 hr.

Plugging these values into the formula, we get: mL/hr = 750 / 8. Simplifying this fraction, we get: mL/hr = 93.75.

Since we need to round to the nearest whole number, the final answer is: mL/hr = 94. Therefore, the nurse should set the IV pump to deliver 94 mL/hr.

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Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Correct Answer is C

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NaCl) 750 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["94"]

Explanation

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