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A nurse in an emergency department (ED) is admitting a client.
Exhibits
Select 4 findings in the client's medical record that place them at risk for pneumonia.

Pneumococcal vaccine

Level of consciousness

Influenza vaccine

Health history

Fluid intake

Age

Smoking history

Answer and Explanation

Correct Answer : A,C,E,F

A.   The client has not received pneumococcal vaccine, which increases susceptibility to pneumococcal pneumonia.
B.   The client is oriented to time place and person which is normal.
C.   The client has not received influenza vaccine, which increases susceptibility to pneumococcal pneumonia.
D.   The client has no significant health history other than the primary concern.
E.   The client's fluid intake seems to be reduced, as indicated by their decreased urination and reports of not drinking much water due to a sore throat, which can contribute to the risk of infection.
F.   Being 70 years old increases susceptibility to respiratory infections like pneumonia.
G.   No history of smoking reduces risk compared to smokers, but is still a risk factor in pneumonia development.

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Correct Answer is B

Explanation

Rationale:
A. Elevated ST segment is typically associated with myocardial infarction or pericarditis, not hypokalemia.
B. An abnormally prominent U wave is a classic sign of hypokalemia on an EKG.
C. Wide QRS complex can be seen with severe hyperkalemia or other conditions affecting ventricular conduction.
D. Inverted P wave is not associated with hypokalemia; it is more often related to atrial conduction abnormalities or ectopic atrial rhythm.

A. Check the IV site for bleeding every 8 hr B. Obtain a rectal temperature every 8 hr. C. Check the client for proteinuria. D. Limit, IM injections.

Correct Answer is D

Explanation

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

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A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse in an emergency department (ED) is admitting a client.
Exhibits
Select 4 findings in the client's medical record that place them at risk for pneumonia.