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
Correct Answer : B,D,E,F
A. Pneumococcal vaccine → Not having it increases risk, but the option itself (“Pneumococcal vaccine”) is misleading; risk comes from lack of vaccine, not its presence.
B. Level of consciousness → Client is lethargic and has difficulty answering questions, which can increase risk of aspiration and reduce effective airway clearance.
C. Influenza vaccine → Similarly, not getting the vaccine is a risk, but the option is phrased as “Influenza vaccine,” which is protective, not a risk factor.
D. Health history → Lack of pneumococcal and influenza vaccinations increases susceptibility to respiratory infections.
E. Fluid intake → Client reports reduced fluid intake, leading to thickened secretions, impaired mucociliary clearance, and higher risk of pneumonia.
F. Age → Middle-aged and older adults are at higher risk for pneumonia due to decreased physiologic reserve.
G. Smoking history → Smoking history is incorrect. While a history of smoking, or exposure to second-hand smoke, increases a client’s risk of contracting community-acquired pneumonia, the client reports no smoking history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.
Correct Answer is B
Explanation
Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
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