Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
43. An 84-year-old with diabetes and left leg cellulitis is brought to an emergency department. Vital signs are: BP 132/90 mm Hg, T 99.4°F, P 95, and R 20. Blood glucose is 98. Left leg is red and swollen. The client is admitted to a nursing unit. Which order should be a priority for the nurse?
. Start ampicillin of 1 gm every 8 hours.
. Obtain an ECG.
. Administer insulin for elevated blood sugar.
. Draw blood cultures.
Test-Taking Tip
This is a priority question—more data are needed to identify the cause of the infection ("itis").
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because blood cultures are done before treatment. Answer 2 is incorrect because there is no indication of cardiac involvement. Answer 3 is incorrect because blood glucose is not elevated at this time (although diabetes is a risk factor for cellulitis). Answer 4 is correct because a low-grade temperature and elevated pulse in an older adult are consistent with infection. The specific bacteria causing the infection of the skin and subcutaneous tissue should be identified to prevent sepsis.