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 B
Explanation
A. The T wave in the inverted position can indicate ischemia or electrolyte imbalances but does not define normal sinus rhythm.
B. The P wave falling before the QRS complex is characteristic of normal sinus rhythm.
C. A QRS duration of 0.20 seconds is within the normal range and does not specifically define normal sinus rhythm.
D. The P-R interval typically ranges from 0.12 to 0.20 seconds, and a slightly prolonged interval here wouldn't necessarily exclude normal sinus rhythm.
Correct Answer is C
Explanation
A. Hiccups are not a common adverse effect of morphine.
B. Heartburn is not a common adverse effect of morphine.
C. Orthostatic hypotension is a known adverse effect of morphine due to its potential to cause vasodilation and lower blood pressure, especially when the client changes positions.
D. Diarrhea is not a common adverse effect of morphine; constipation is more likely.
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