how should a nurse assess a patient with suspected sepsis

ATI LPN

ATI PN Comprehensive Predictor 2020 Answers

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

A. Monitor vital signs and administer antibiotics
B. Monitor for signs of infection and confusion
C. Monitor for fever and check oxygen saturation
D. Assess for confusion and administer fluids

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. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

A. Avoid taking blood pressures on the arm with the AV fistula.
B. Check the fistula site daily for pallor.
C. Place a warm compress over the fistula site every 4 hours.
D. Keep the client's arm elevated on two pillows.

Correct answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

3. A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

A. I had a bowel movement, but I was able to save the urine.
B. I have a specimen in the bathroom from about 30 minutes ago.
C. I flushed what I urinated at 7 am and have saved the rest since.
D. I drink a lot, so I will fill up the bottle and complete the test quickly.

Correct answer: C

Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.

4. What are the risk factors for developing hypertension?

A. High sodium diet and lack of physical activity
B. Low potassium intake and excessive alcohol consumption
C. Frequent exercise and low cholesterol diet
D. Smoking and family history

Correct answer: A

Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.

5. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

A. Perform the test in the morning after taking medications
B. Blow into the meter as slowly as possible
C. Perform the test when feeling short of breath
D. Use the peak flow meter after using your rescue inhaler

Correct answer: D

Rationale: The correct instruction is to use the peak flow meter after using the rescue inhaler. This ensures accurate monitoring of asthma control during symptoms. Choice A is incorrect because peak flow measurements should be done before taking medications. Choice B is incorrect as the client should blow into the meter quickly and forcefully to get an accurate reading. Choice C is also incorrect as peak flow should be measured regularly, not just when feeling short of breath.