Author Question: The nurse caring for a client with septicemia plans care based on the nursing diagnosis of altered ... (Read 55 times)

brutforce · **on:** Jul 22, 2018

The nurse caring for a client with septicemia plans care based on the nursing diagnosis of altered tissue perfusion. Which of the following interventions is the priority for this client?

1. Assess temperature every hour
2. Check peripheral pulses every hour
3. Monitor heart rate every hour
4. Monitor pupil reactions every hour

Question 2

The nurse is caring for an Asian American client who is in the hospital for chemotherapy via central line. The nurse plans to check this client frequently for signs of impending sepsis because Asian clients:

1. Are more prone to sepsis.
2. Are poorly nourished.
3. Perceive reporting symptoms as complaining.
4. Do not respond well to chemotherapy.

nanny · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2. Check peripheral pulses every hour

Rationale:
The fastest and best method of checking perfusion is to monitor peripheral pulses, capillary refill, color, and temperature of distal limbs. Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but pulse checks will alert the nurse immediately of decreased tissue perfusion.

Answer to Question 2

3. Perceive reporting symptoms as complaining.

Rationale:
In the Asian culture, it is a sign of weakness to complain. The nurse would want to check the client frequently for signs and symptoms of impending sepsis since this client has a compromised immune system from chemotherapy and a central line. There is no evidence that Asian people are more prone to sepsis or that they are undernourished. There is also no evidence that the Asian client will respond poorly to chemotherapy.