how should a nurse assess a patient with suspected sepsis
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ATI PN Comprehensive Predictor 2020 Answers

1. How should a healthcare professional assess a patient with suspected sepsis?

Correct answer: A

Rationale: When assessing a patient with suspected sepsis, it is crucial to monitor vital signs like temperature, heart rate, respiratory rate, and blood pressure. Administering antibiotics promptly is also vital to treat the infection causing sepsis. This approach helps in preventing the progression of sepsis to severe stages and reduces the risk of complications. Choice B is incorrect because only monitoring signs of infection and confusion may delay necessary treatment with antibiotics. Choice C is incorrect as it focuses only on fever and oxygen saturation, missing other important vital signs. Choice D is incorrect because assessing for confusion alone is not sufficient, and administering fluids should be guided by the patient's fluid status rather than being an initial step in suspected sepsis assessment.

2. What is the right to make one's own personal decisions, even though those decisions might not be in the person's best interest?

Correct answer: A

Rationale: The correct answer is A: Autonomy. Autonomy is the right to make one's own decisions, even if they may not be in the person's best interest. Autonomy emphasizes an individual's freedom to choose and act according to their own values and beliefs. Non-maleficence (B) refers to the principle of 'do no harm,' Justice (C) refers to fairness and equality in the distribution of resources or benefits, and Beneficence (D) refers to the obligation to do good and act in the patient's best interest.

3. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

Correct answer: B

Rationale: During pregnancy, a client with type 2 diabetes mellitus should aim for a weight gain similar to someone without diabetes to ensure a healthy pregnancy. Choice A is incorrect because weight gain should not be less; it should be adequate for pregnancy. Choice C is inaccurate as gaining some weight is essential for a healthy pregnancy. Choice D is incorrect as gaining more weight than necessary can pose risks for both the client and the baby.

4. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?

Correct answer: A

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.

5. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?

Correct answer: D

Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.

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