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 : 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A positive Western blot test confirms HIV infection but does not provide immediate information on the client's immune status.
B. Platelets within the normal range are important but do not directly indicate the client's immune status or HIV progression.
C. CD4-T-cell count is crucial for monitoring HIV progression and immune function. A low count indicates immunosuppression and increased risk of opportunistic infections.
D. WBC count is important but does not specifically indicate the client's HIV status or immune function related to HIV.
Correct Answer is C
Explanation
Rationale:
A. Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.
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