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:
-
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","B","E","F"]
Explanation
Choice A rationale:
Givingtheclientprintedinformationisaneducationalmethodthatinvolvesreadingandcomprehension,whicharekeycomponentsofthecognitivedomain.
Choice B rationale:
Teaching about expected reference ranges and target blood glucose levels is based on the cognitive domain of learning. This involves understanding and comprehending information, which is a key aspect of cognitive learning. It's important for a client with diabetes to know what their blood glucose levels should be and what values to aim for to manage their condition effectively.
Choice C rationale:
Asking the client how they feel about checking their blood glucose levels is related to the affective domain of learning. It focuses on the client's emotions and attitudes rather than cognitive understanding, which is not directly mentioned in the question.
Choice D rationale:
Asking the client to demonstrate checking their blood glucose level is based on the psychomotor domain of learning. This involves physical skills and actions, which are not explicitly mentioned in the question.
Choice E rationale:
Giving the client a fill-in-the-blank quiz is also based on the cognitive domain of learning. Quizzes and assessments are tools that help assess a client's understanding and retention of information, which aligns with cognitive learning.
Choice F rationale:
Asking the client to describe the manifestations of hypoglycemia and hyperglycemia is also based on the cognitive domain of learning. It requires the client to recall and explain information, which is a cognitive process.
Correct Answer is B
Explanation
Choice A rationale:
Quality of practice involves the nurse's competence in providing care to patients and ensuring that the care meets established standards. Violating the quality of practice standard would typically involve issues related to the quality and safety of care provided. In this scenario, the nurse's violation is related to accessing a client's medical record without being involved in their care, which is an ethical breach rather than a violation of the quality of practice standard.
Choice B rationale:
Code of ethics is the standard of professional performance that the nurse is violating. Accessing a client's medical record without being involved in their care is a violation of the ethical principles outlined in the Code of Ethics for Nurses. This action breaches patient confidentiality and privacy, which are fundamental ethical obligations for nurses.
Choice C rationale:
Collaboration involves working effectively with other healthcare professionals to provide optimal patient care. Violations of the collaboration standard would typically involve issues related to teamwork, communication, and interdisciplinary relationships. The scenario described does not pertain to collaboration but rather concerns ethical conduct.
Choice D rationale:
Evidence-based practice refers to the integration of current research evidence into clinical decision-making and patient care. Violations of evidence-based practice would involve not following the latest research and best practices in patient care. In this case, the nurse's violation is related to ethical principles and patient privacy rather than evidence-based practice.
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