A nurse is caring for a client in an acute care setting.
Complete the following sentence by using the list of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The client is at risk for hypostatic pneumonia as evidenced by the client's immobility
Rationale
The combination of paraplegia (which leads to limited mobility) and symptoms such as productive cough, tachycardia, and confusion suggest a respiratory issue, likely hypostatic pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Recommending clients for discharge may be premature and disrupt ongoing care, potentially worsening the situation if those clients require immediate care.
B. While determining the medical needs of incoming clients through the emergency department is important, the immediate priority is ensuring sufficient staffing for the current medical needs.
C. Acting as a liaison between the facility and the media is an important role, but it is not the nurse's primary responsibility during a mass casualty event. The nurse should focus on direct patient care.
D. Calling in additional nursing staff ensures the facility has adequate personnel to care for the incoming patients, especially given the likely influx of critically ill or injured clients.
Correct Answer is C
Explanation
A. Medical care cannot be initiated based on the absence of legal assistance for advance directives; this is not an appropriate response.
B. While a social worker may assist with legal issues, this is not the immediate response to the client’s
concern.
C. Advance directives can be legally valid without the need for an attorney, and this can reassure the client.
D. Advance directives must be written or documented in a specific format, and verbal agreements are insufficient.
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