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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 ["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 ["0.5"]

Explanation

To administer the correct dose of lorazepam, which is 1 mg, when only 2 mg tablets are available, the nurse should administer half a tablet. This is because each tablet contains 2 mg of lorazepam, and the prescribed dose is 1 mg. Therefore, dividing the tablet into two equal parts will provide the necessary 1 mg dose. The answer, rounded to the nearest tenth as per the instruction, is 0.5.

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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

36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

Correct Answer is ["C","D"]

Explanation

A nurse is preparing to administer lorazepam 1 mg PO at bedtime. The amount available is lorazepam 2 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

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.