After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider?
a. Temperature and IV site appearance
b. Oxygen saturation and breath sounds
c. Platelet count and presence of petechiae
d. Blood pressure, pulse rate, respiratory rate.
ANS: C
The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS) is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.
You might also like to view...
The home care nurse sees a patient for the first time. The patient has crackles in the lower lobes of the lungs, an audible S3, and pitting edema in the feet and ankles. What condition is the patient experiencing?
A) Pneumonia B) Liver disease C) Congestive heart failure D) Myocardial infarction
The nurse manager is assessing safe medication administration in preparation for the Joint Commission's (TJC) visit to the hospital. Which observed action is not recommended according to the TJC's National Patient Safety Goals?
A) Labeling all medicines that will be administered to the client appropriately B) Using extra caution with blood thinners C) Taking care when recording client medicine information D) Allowing the client to keep home meds at the bedside for use while in the hospital
During the post-operative care of a 76-year old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because
A. Older adults have an impaired thirst mechanism and need reminding to drink fluids. B. Water accounts for a greater percentage of body weight in the older adult than in younger adults. C. Older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. D. Small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults.
________ is a syndrome characterized by slowing of movement, stiffness, tremor, and impaired postural reflexes.
Fill in the blank(s) with the appropriate word(s).