Prep U: Chapter 30

A nurse suspects that a client may be developing sepsis based on assessment findings. The practitioner orders a serum lactate level to be obtained. When reviewing the results, which serum lactate level would the nurse identify as indicative of sepsis?

4.6 mmol/liter

A nurse is reviewing a patient's complete white blood cell count and differential. The nurse determines that the patient is experiencing neutropenia based on which absolute neutrophil count?

800 cells/mm3

A nurse is reviewing the white blood cell count and differential of a client and notes that there is a significant shift to the left. The nurse interprets this as indicating which of the following?

Client has developed a bacterial infection.

After explaining to students about the progression of infection, an instructor determines that teaching was successful when the students identify which of the following as the time during which a disease can be passed from one person to another?

Communicable period

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely which of the following?

Greater than 40.5C

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

Helps to determine prescribed antibiotic therapy

The nurse assessing a client who had elevated temperature an hour ago determines that the client is in the crisis phase of fever. Which of the folloiwng would lead the nurse to this conclusion?

Profuse diaphoresis

A nurse is providing care for a client who has had gall bladder surgery. It is the first postoperative day and the client is exhibiting a fever. The nurse suspects which of the following as the most likely cause?

Stress of surgery

A group of nursing students are reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T Lymphocytes

A patient presents to the clinic with complaints of fever and abdominal pain. Blood work shows an elevated white count. This patient is what?

acute phase The acute phase of illness is the state in which the infected host displays a decline in wellness due to the infection.

While reviewing a client's medical record, a nurse notes the different laboratory tests results of the client. Which of the following would the nurse identify as important in detecting an antigen-antibody response?

serology

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate?

"Stress leads to increased secretion of cortisol, which suppreses your immune response."

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for which time frame?

3 days

A nurse is reviewing the laboratory test results of a client who at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis?

3.2 mmol/L

You are caring for a client with an impaired immune system. You are concerned about the client acquiring a nosocomial infection. What intervention would the nurse focus on to help control nosocomial infections?

Apply principles of medical and surgical asepsis.

A patient develops a fever. When assessing the patient, the nurse determines that the patient is in the crisis phase based on assessment of which of the following?

Flushed skin

The physician orders a serum trough drug level for a client who is receiving antibiotic therapy. The client is receiving the drug every 6 hours, at midnight, 6 AM, noon and 6 PM. A which time would the nurse anticipate the specimen would be obtained?

Just before the 6 AM dose

During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period?

Prodromal period

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?

The client's heart rate is greater than 90 beats per minute.

Which of the following would be considered a mechanical defense mechanism?

coughing

A nurse is developing a presentation for a local community group about infections and resistance to them. When describing acquired specific defenses, which of the following would the nurse most likely include?

humoral immunity