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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: These drugs kill the virus is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is inaccurate and misleading. Antiretroviral drugs do not kill the virus, but rather block or interfere with the enzymes or proteins that the virus needs to replicate or integrate into the host cells. Antiretroviral drugs can reduce the viral load, which is the amount of virus in the blood, but they cannot eliminate the virus completely.
Choice B reason: Only certain licensed drugs are effective is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is vague and incomplete. Antiretroviral drugs are licensed and approved by the regulatory authorities, such as the Food and Drug Administration (FDA), based on their safety and efficacy. However, not all licensed drugs are equally effective for all people with HIV, as the virus can develop resistance or mutation to some drugs over time. Therefore, the choice and combination of antiretroviral drugs may vary depending on the individual's viral genotype, drug history, and drug interactions.
Choice C reason: A few missed doses per month are OK is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is incorrect and dangerous. Antiretroviral drugs require strict adherence and compliance, which means taking the drugs exactly as prescribed, without missing or skipping any doses. A few missed doses per month are not OK, as they can reduce the effectiveness of the drugs and increase the risk of viral resistance or mutation, which can lead to treatment failure or disease progression.
Choice D reason: These drugs inhibit viral replication is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it describes the mechanism and outcome of the drugs. Antiretroviral drugs inhibit viral replication, which means they prevent or slow down the multiplication or reproduction of the virus. Antiretroviral drugs can inhibit viral replication by targeting different stages of the viral life cycle, such as reverse transcription, integration, or maturation. Antiretroviral drugs can improve the immune function and quality of life of people with HIV.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Increased agitation is a nonverbal sign of pain, because it indicates that the client is restless, uncomfortable, or distressed by the pain. Agitation can manifest as fidgeting, tossing, turning, moaning, or groaning.
Choice B reason: Decreased attention span is not a nonverbal sign of pain, but rather a cognitive or behavioral sign of pain. Decreased attention span means that the client has difficulty focusing, concentrating, or remembering things, which can be affected by pain. However, decreased attention span is not a direct expression of pain, but rather a consequence of pain.
Choice C reason: Grimacing is a nonverbal sign of pain, because it indicates that the client is experiencing facial muscle tension, contraction, or distortion due to the pain. Grimacing can manifest as frowning, wrinkling the forehead, pursing the lips, or clenching the teeth.
Choice D reason: Reported pain of 5/10 is not a nonverbal sign of pain, but rather a verbal sign of pain. Reported pain of 5/10 means that the client has communicated the intensity of their pain using a numerical scale, which is a subjective and selfreported measure of pain. However, reported pain of 5/10 is not a direct expression of pain, but rather a description of pain.
Choice E reason: Increase in heart rate is a nonverbal sign of pain, because it indicates that the client is experiencing physiological changes due to the pain. Increase in heart rate can manifest as tachycardia, palpitations, or arrhythmias.
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