A nurse is caring for a client.
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Medication Administration Record:
- Budesonide 6 mg PO daily.
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Laboratory Results:
- Hematocrit (Hct): 47% (Normal range: 37% to 52%)
- Hemoglobin (Hgb): 16 g/dL (Normal range: 12 to 18 g/dL)
- Potassium: 3.6 mEq/L (Normal range: 3.5 to 5.0 mEq/L)
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History and Physical:
- BMI: 16 (Reference Range:18.5 - 24.9)
- History of type 2 diabetes mellitus.
- Nonsmoker.
- New diagnosis of Crohn's disease.
Click to highlight the findings that increase the client's susceptibility to infection.
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Budesonide 6 mg PO daily
BMI: 16
History of type 2 diabetes mellitus
New diagnosis of Crohn's disease
Hematocrit (Hct): 47%
Hemoglobin (Hgb): 16 g/dL
Potassium: 3.6 mEq/L
The Correct Answer is ["A","B","C","D"]
Findings that Could Increase Susceptibility to Infection:
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Budesonide 6 mg PO daily:
- Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.
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BMI of 16:
- Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.
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History of Type 2 Diabetes Mellitus:
- Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.
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New Diagnosis of Crohn's Disease:
- Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.
Findings That Do Not Increase Susceptibility to Infection:
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Hematocrit (Hct) of 47%:
- Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.
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Hemoglobin (Hgb) of 16 g/dL:
- Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.
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Potassium level of 3.6 mEq/L:
- Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Using a cell phone to request assistance from the client's room ensures timely communication and enhances patient care. Quick access to help can be vital in emergency situations, ensuring prompt and effective intervention.
Choice B rationale: Sending a personal text to a co-worker during work hours is unprofessional and can lead to distractions. It can compromise patient care and violates workplace policies on personal device usage, ensuring focus remains on patient safety and care.
Choice C rationale: Calling the client's family member per their request can violate privacy and confidentiality regulations, such as HIPAA in the US. Communication with family should go through proper channels to ensure compliance with legal and ethical standards.
Choice D rationale: Taking a photo of a client's incision site for learning purposes without proper consent and documentation breaches patient confidentiality and privacy. It could also result in legal ramifications and violates institutional policies on using personal devices for work-related tasks.
Correct Answer is D
Explanation
Choice D rationale:
Protecting a client's safety by not causing harm refers to the ethical principle of nonmaleficence. Nonmaleficence emphasizes the duty of healthcare professionals to avoid harm or minimize harm when providing care to clients. This principle is closely related to the concept of "do no harm" and places a high value on the well-being and safety of the client. Nurses must make decisions and take actions that prioritize the client's safety and well-being, even when faced with difficult ethical dilemmas.
Choice A rationale:
Beneficence is the ethical principle that emphasizes doing good and promoting the well-being of the client. While it is an essential ethical principle in nursing, it is not directly related to the concept of not causing harm, as described in the question.
Choice B rationale:
Fidelity, also known as faithfulness or loyalty, pertains to the nurse's obligation to uphold commitments and keep promises made to the client. While fidelity is crucial in nursing practice, it is not the primary principle related to the concept of not causing harm.
Choice C rationale:
Justice is the ethical principle concerned with fairness and the equitable distribution of healthcare resources and treatment. It focuses on providing clients with their due and ensuring that they are treated fairly and without discrimination. Justice is important in healthcare ethics but is not directly associated with the principle of not causing harm.
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