A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?
The client is in a private room.
The client has a dedicated vital signs machine.
The client has a vase of fresh flowers on the table.
There is hand sanitizer by the door.
The Correct Answer is C
Choice A reason: The client is in a private room is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should be in a private room, as it can reduce the exposure to pathogens or allergens that may cause infection or inflammation. The client with reduced immunity has a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection. The private room can also provide privacy, comfort, and security for the client.
Choice B reason: The client has a dedicated vital signs machine is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have a dedicated vital signs machine, as it can prevent the crosscontamination or transmission of pathogens or allergens that may cause infection or inflammation. The vital signs machine is a device that measures the blood pressure, pulse, temperature, and oxygen saturation of the client. The vital signs machine can be contaminated by the blood, body fluids, or secretions of the client or other clients, and can harbor bacteria, viruses, or fungi. The dedicated vital signs machine can also ensure the accuracy, consistency, and availability of the measurements for the client.
Choice C reason: The client has a vase of fresh flowers on the table is an observation that requires further action by the nurse, because it is inappropriate and undesirable. The client with reduced immunity should not have a vase of fresh flowers on the table, as it can increase the exposure to pathogens or allergens that may cause infection or inflammation. The fresh flowers are a source of mold, pollen, or insects, which can trigger allergic reactions, respiratory distress, or skin irritation. The fresh flowers can also contain bacteria, viruses, or fungi, which can infect the client through inhalation, ingestion, or contact. The vase of fresh flowers should be removed from the room and replaced with artificial flowers, pictures, or cards.
Choice D reason: There is hand sanitizer by the door is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have hand sanitizer by the door, as it can promote the hand hygiene and infection prevention of the client and others. Hand sanitizer is a product that contains alcohol or other agents that can kill or reduce the number of pathogens or allergens that may cause infection or inflammation. Hand sanitizer should be used by the client, the staff, and the visitors before and after entering or leaving the room, or after touching any objects or surfaces in the room.
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Correct Answer is D
Explanation
Choice A reason: Determine whether it is temporary or permanent is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Determining whether the compromised immunity is temporary or permanent is an important assessment, but it should be done after ensuring the safety and infection prevention of the client. Compromised immunity can be temporary or permanent, depending on the cause, such as medication, disease, or genetic disorder.
Choice B reason: Take the client's vital signs every four hours is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Taking the client's vital signs every four hours is an important monitoring, but it should be done after ensuring the safety and infection prevention of the client. Vital signs can indicate the general health status and the presence of infection or inflammation, such as fever, tachycardia, or hypotension.
Choice C reason: Teach the family members to receive the flu shot annually is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Teaching the family members to receive the flu shot annually is an important education, but it should be done after ensuring the safety and infection prevention of the client. The flu shot is a vaccine that can protect the family members and the client from influenza, which can be a serious and potentially fatal infection for people with compromised immunity.
Choice D reason: Wash hands before entering the client's room is the nurse's priority action for a client with compromised immunity, because it is the most urgent and relevant. Washing hands before entering the client's room is a basic and essential infection prevention measure, which can protect the client from exposure to pathogens that can cause infection. People with compromised immunity have a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection.
Correct Answer is A
Explanation
Choice A reason: Fistula is a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin. Fistula can occur as a result of infection, inflammation, trauma, surgery, or congenital defect. Fistula can cause pain, bleeding, discharge, or leakage of fluids or gases from the affected organs or tissues. Fistula can also increase the risk of infection, obstruction, or perforation of the involved organs or tissues.
Choice B reason: Hemorrhage is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an excessive or uncontrolled bleeding from the wound site. Hemorrhage can occur as a result of trauma, surgery, infection, or coagulation disorder. Hemorrhage can cause pain, swelling, bruising, or shock at the wound site. Hemorrhage can also lead to blood loss, anemia, or hypovolemia.
Choice C reason: Infection is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an invasion and multiplication of microorganisms in the wound site. Infection can occur as a result of contamination, poor hygiene, or impaired immunity. Infection can cause pain, redness, warmth, swelling, or pus at the wound site. Infection can also trigger inflammation, fever, or systemic illness.
Choice D reason: Evisceration is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is a protrusion of internal organs or tissues through the wound site. Evisceration can occur as a result of dehiscence, which is a separation or splitting open of the wound edges. Evisceration can cause pain, bleeding, or shock at the wound site. Evisceration can also expose the internal organs or tissues to injury, infection, or necrosis.
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