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The nurse is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply.
- A. Bleeding times are increased and platelet counts decreased.
- B. Increased urine osmolality and decreased urine output.
- C. Four plus pitting edema of the lower extremities.
- D. Confusion, disorientation, delirium.
- E. Heart rate 78, blood pressure 124/84, and RR of 20.
Correct Answer: A,B,D
Rationale: SIRS presents with coagulopathy (bleeding/platelet issues), renal dysfunction (oliguria, high osmolality), and altered mental status. Pitting edema and normal vital signs are not diagnostic.
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The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP washes her hands before and after performing vital signs on a client.
- B. The UAP dons sterile gloves prior to removing an indwelling catheter from a client.
- C. The UAP raises the head of the bed to a high Fowler's position for a client about to eat.
- D. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for catheter removal, risking improper technique and infection. Handwashing, Fowler’s position, and ice bag use are appropriate.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first?
- A. The client diagnosed with RA complaining of pain at a '3' on a 1-to-10 scale.
- B. The client diagnosed with SLE who has a rash across the bridge of the nose.
- C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
- D. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.
Correct Answer: C
Rationale: Antineoplastic drugs (e.g., methotrexate) pose risks like toxicity, requiring immediate assessment. Mild pain, rashes, and scleroderma are less acute.
Which referral should the nurse implement for a client with severe multiple allergies?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Recreational therapist.
- D. Social worker.
Correct Answer: A
Rationale: A dietitian helps identify food allergens, critical for severe allergies. Other therapists are less relevant.
The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE?
- A. The steroids will increase the body's ability to fight the infection.
- B. The steroids will decrease the chance of the SLE spreading to other organs.
- C. The steroids will suppress tissue inflammation, which reduces damage to organs.
- D. The steroids will prevent scarring of skin tissues associated with SLE.
Correct Answer: C
Rationale: Steroids suppress inflammation in SLE, reducing organ damage. They do not fight infection, prevent disease spread, or address skin scarring primarily.
The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test?
- A. The client will have wires attached to the scalp and lights will flash off and on.
- B. The machine will be loud and the client must not move the head during the test.
- C. The client will drink a contrast medium 30 minutes to one (1) hour before the test.
- D. The test will be repeated at intervals during a five (5)- to six (6)-hour period.
Correct Answer: B
Rationale: MRI machines are loud, and head immobility is critical for clear images. Wires/lights describe EEG, oral contrast is not used for brain MRI, and the test is not repeated over hours.