A nurse is caring for an immobile client. What is the priority assessment in this client?
Assessment for the presence of peripheral edema
Auscultation of lung sounds
Auscultation of bowel sounds
Assessment of skin turgor
The Correct Answer is B
Choice A reason: This is not the priority assessment because peripheral edema is not a lifethreatening complication of immobility. Peripheral edema is the swelling of the lower extremities due to fluid accumulation. It can be caused by various factors, such as venous insufficiency, heart failure, kidney disease, or medication side effects. The nurse should monitor the client's fluid status and provide elevation and compression therapy as needed.
Choice B reason: This is the priority assessment because lung sounds can indicate the presence of respiratory complications, such as pneumonia or atelectasis, which are common and serious consequences of immobility. Pneumonia is an infection of the lungs that causes inflammation, mucus production, and impaired gas exchange. Atelectasis is the collapse of alveoli, which are the tiny air sacs in the lungs that facilitate oxygen and carbon dioxide exchange. The nurse should auscultate the client's lung sounds regularly and report any abnormal findings, such as crackles, wheezes, or diminished breath sounds. The nurse should also encourage the client to cough, deep breathe, and use incentive spirometry to prevent or treat respiratory problems.
Choice C reason: This is not the priority assessment because bowel sounds can reflect the status of the gastrointestinal system, which is not directly affected by immobility. Bowel sounds are the noises produced by the movement of food and gas through the intestines. They can vary in frequency and intensity depending on the client's diet, activity, and medications. The nurse should auscultate the client's bowel sounds and assess for any signs of constipation, diarrhea, or obstruction. The nurse should also promote the client's bowel function by providing adequate hydration, fiber, and laxatives as ordered.
Choice D reason: This is not the priority assessment because skin turgor can indicate the level of hydration, which is not a primary concern of immobility. Skin turgor is the elasticity of the skin that allows it to return to its normal shape after being pinched or pulled. It can be affected by factors such as age, weight loss, dehydration, or edema. The nurse should assess the client's skin turgor and provide adequate fluids and electrolytes as needed. The nurse should also pay attention to the client's skin integrity and prevent or treat any pressure ulcers or wounds that may result from immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Calling the chaplain for support is not the priority nursing intervention for a client who speaks only Spanish. The chaplain may not be able to communicate with the client or understand their needs. This choice does not address the language barrier or the client's reason for admission.
Choice B reason: Verifying the reason for admission is an important nursing intervention, but it is not the priority for a client who speaks only Spanish. The nurse cannot verify the reason for admission without communicating with the client or their family. This choice does not address the language barrier or the client's safety.
Choice C reason: Requesting a medical interpreter is the priority nursing intervention for a client who speaks only Spanish. The medical interpreter can facilitate communication between the nurse and the client, and help the nurse assess the client's condition, reason for admission, and needs. This choice addresses the language barrier and the client's safety.
Choice D reason: Giving the client a tour of the unit is not the priority nursing intervention for a client who speaks only Spanish. The client may not understand the tour or the information given by the nurse. This choice does not address the language barrier or the client's reason for admission.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect answer because a pathogenic infection is caused by a microorganism that can cause disease in a healthy host. Pathogens are usually able to overcome the host's immune defenses and cause symptoms and damage. Examples of pathogenic infections are strep throat, tuberculosis, and malaria.
Choice B reason: This is the correct answer because an opportunistic infection is caused by a microorganism that normally does not cause disease in a healthy host, but can take advantage of a weakened immune system and cause serious illness. Opportunistic infections are common and often lifethreatening complications of HIV infection, as the virus destroys the CD4 cells that help fight infections. Examples of opportunistic infections are pneumocystis pneumonia, candidiasis, and toxoplasmosis.
Choice C reason: This is an incorrect answer because a nosocomial infection is acquired in a health care setting, such as a hospital, clinic, or nursing home. Nosocomial infections are usually caused by microorganisms that are resistant to antibiotics and can spread easily among patients and staff. Examples of nosocomial infections are methicillinresistant Staphylococcus aureus (MRSA), Clostridioides difficile (C. diff), and urinary tract infections.
Choice D reason: This is an incorrect answer because a root cause infection is not a valid term in medical terminology. A root cause is the underlying factor or reason that leads to a problem or outcome. A root cause analysis is a process of identifying and addressing the root causes of a problem or event, such as an infection, to prevent recurrence and improve quality and safety.
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