A client with open burn wounds begins to have diarrhea. The client is found to have a be-low-normal temperature, with a white blood cell count of 4000/mm3 . Which action by the nurse is most appropriate?
a. Continue to monitor the client.
b. Increase the temperature in the room.
c. Increase the rate of intravenous fluids.
d. Prepare to do a workup for sepsis.
D
These findings are associated with systemic Gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increas-ing the temperature in the room may make the client more comfortable, but the priority is finding out whether the client has sepsis and treating it before it becomes a shock situation. The rate of intravenous fluids may be increased to replace fluid losses associated with diarrhea, but this is not the priority action.
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A tumor may be benign or malignant
True False