A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.The nurse should identify which of the following findings as indicative of an infection?
Milky fluid.
Bloody fluid.
Viscous fluid.
Purulent fluid.
The Correct Answer is D
Choice A rationale
Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.
Choice B rationale
Bloody fluid may indicate trauma or malignancy but not necessarily infection.
Choice C rationale
Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.
Choice D rationale
Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
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Correct Answer is C
Explanation
Choice A rationale
Acetaminophen can be hepatotoxic in clients with liver damage, so it should be avoided. This is especially critical for clients with cirrhosis, where liver function is already compromised.
Choice B rationale
Eating three large meals can be overwhelming for someone with cirrhosis, as the liver is less able to process nutrients efficiently. Smaller, more frequent meals are advised.
Choice C rationale
Avoiding high-sodium foods is crucial because cirrhosis often leads to fluid retention and ascites, which can be exacerbated by a high-sodium diet.
Choice D rationale
Increasing activity as much as possible may not be safe for someone with cirrhosis, who often experiences fatigue and muscle wasting. Activity should be balanced with rest and tolerance levels.
Correct Answer is A
Explanation
Choice A rationale
Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.
Choice B rationale
Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.
Choice C rationale
Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.
Choice D rationale
Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.