Inflammation

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Sample questions from Inflammation

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, a 68-year-old client admitted with cellulitis has a temperature of 39.2 C, HR 126/min, RR 28/min, BP 86/50 mm Hg, and new confusion. Which action should the nurse take first?

   • A.Obtain a wound culture before notifying the provider
   • B.Activate the rapid response system and initiate the sepsis response
   • C.Elevate the affected leg and reassess the erythema
   • D.Administer the prescribed oral acetaminophen

   Rationale: Hypotension, tachycardia, fever, tachypnea, and acute confusion suggest sepsis with impaired perfusion, requiring immediate escalation. Elevation and acetaminophen do not address the unstable circulation. A culture may be appropriate, but obtaining it must not delay emergency response.

2. 2.In the emergency department, a 72-year-old client being treated for pneumonia has worsening oxygen needs and a rising temperature. Which action should the nurse take first?

   • A.Encourage oral fluids and reassess in 1 hour
   • B.Document the findings and wait for the next scheduled assessment
   • C.Notify the provider of the worsening oxygenation and temperature trend
   • D.Request an antipyretic for the elevated temperature

   Rationale: The rising oxygen requirement with fever indicates worsening respiratory infection and possible progression to sepsis; prompt provider notification enables escalation of care. Fluids and an antipyretic may be appropriate adjuncts but do not address the respiratory decline. Waiting or documenting without action is unsafe.

3. 3.During a home health visit, a 74-year-old client with a draining lower-leg wound reports increased pain and chills. The wound is warm with spreading redness; temperature is 38.3 C. Which actions should the nurse take? Select all that apply.

   • A.Assess and document the extent of erythema and drainage
   • B.Clean the wound using the prescribed wound-care technique
   • C.Apply a heating pad directly to the wound to draw out infection
   • D.Arrange prompt medical evaluation for possible spreading infection
   • E.Advise the client to stop prescribed antibiotics once the fever resolves

   Rationale: Documenting wound changes establishes a baseline, and fever with spreading redness warrants prompt evaluation. Prescribed wound cleansing reduces contamination and supports care. Direct heat can injure skin, and antibiotics should be taken for the full prescribed course, not stopped when symptoms improve.

4. 4.On a pediatric unit, a 6-year-old with appendicitis has new abdominal rigidity, increasing pain, and a temperature of 38.8 C while awaiting surgery. Which action is the priority?

   • A.Apply a warm compress to the abdomen
   • B.Encourage the child to walk in the hallway
   • C.Offer a high-fiber snack to promote bowel movement
   • D.Notify the surgeon promptly about possible perforation and peritonitis

   Answer and rationale are in the full material.

5. 5.A charge nurse on an oncology unit is assigning care for a 59-year-old client with neutropenia and a new oral temperature of 38.1 C. Which task is appropriate to delegate to an experienced practical nurse?

   • A.Obtain a prescribed blood culture using the established procedure
   • B.Develop the plan for managing the client's fever and neutropenia
   • C.Determine whether the client needs transfer to intensive care
   • D.Perform the initial assessment of the client's possible sepsis

   Answer and rationale are in the full material.