What is the nurse's priority action for a client with compromised immunity?

Determine whether it is temporary or permanent

Take the client's vital signs every four hours

Teach the family members to receive the flu shot annually

Wash hands before entering the client's room

Answer and Explanation

The Correct Answer is D

Choice A reason: Determine whether it is temporary or permanent is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Determining whether the compromised immunity is temporary or permanent is an important assessment, but it should be done after ensuring the safety and infection prevention of the client. Compromised immunity can be temporary or permanent, depending on the cause, such as medication, disease, or genetic disorder.

Choice B reason: Take the client's vital signs every four hours is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Taking the client's vital signs every four hours is an important monitoring, but it should be done after ensuring the safety and infection prevention of the client. Vital signs can indicate the general health status and the presence of infection or inflammation, such as fever, tachycardia, or hypotension.

Choice C reason: Teach the family members to receive the flu shot annually is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Teaching the family members to receive the flu shot annually is an important education, but it should be done after ensuring the safety and infection prevention of the client. The flu shot is a vaccine that can protect the family members and the client from influenza, which can be a serious and potentially fatal infection for people with compromised immunity.

Choice D reason: Wash hands before entering the client's room is the nurse's priority action for a client with compromised immunity, because it is the most urgent and relevant. Washing hands before entering the client's room is a basic and essential infection prevention measure, which can protect the client from exposure to pathogens that can cause infection. People with compromised immunity have a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection.

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Correct Answer is A

Explanation

Choice A reason: Alcohol can trigger a gout attack because it increases the production and decreases the excretion of uric acid, which is the substance that causes inflammation and pain in the joints. Alcohol also dehydrates the body, which can worsen the symptoms of gout.

Choice B reason: Fruit juice is not a beverage that can trigger a gout attack. Fruit juice contains natural sugars and antioxidants, which may have a beneficial effect on the uric acid levels and the inflammation in the body. However, fruit juice should be consumed in moderation, as excess sugar intake can lead to weight gain and other health problems.

Choice C reason: Milk is not a beverage that can trigger a gout attack. Milk contains protein and calcium, which may help lower the uric acid levels and the risk of gout. Milk also has antiinflammatory properties, which may reduce the pain and swelling in the joints.

Choice D reason: Coffee is not a beverage that can trigger a gout attack. Coffee contains caffeine and antioxidants, which may have a protective effect on the uric acid levels and the inflammation in the body. Coffee also has a diuretic effect, which may help flush out the excess uric acid from the kidneys.

A. A client with an unknown skin infection B. A client that recently traveled and developed a fever with cough C. A high school wrestling champion with a rash D. A client with heart palpitations

Correct Answer is B

Explanation

Choice A reason: This is not the correct answer because a skin infection is not transmitted by airborne droplets. A skin infection is usually caused by bacteria, fungi, or parasites that invade the skin and cause inflammation, redness, itching, or pus. A skin infection can be contagious by direct contact with the infected area or by sharing personal items, such as towels, clothing, or razors. The client with a skin infection should be placed in isolation for contact precautions, which involve wearing gloves and gowns and using disposable equipment.

Choice B reason: This is the correct answer because a fever with cough can be a sign of a respiratory infection that is transmitted by airborne droplets. A respiratory infection is caused by viruses, bacteria, or fungi that infect the lungs, throat, or nose and cause symptoms such as fever, cough, sore throat, or difficulty breathing. A respiratory infection can be contagious by inhaling the tiny droplets that are released when the infected person coughs, sneezes, or talks. The client with a respiratory infection should be placed in isolation for airborne precautions, which involve wearing a respirator mask and placing the client in a negative pressure room.

Choice C reason: This is not the correct answer because a rash is not transmitted by airborne droplets. A rash is a change in the color, texture, or appearance of the skin that can be caused by various factors, such as allergies, infections, medications, or injuries. A rash can be contagious by direct contact with the affected skin or by sharing personal items, such as clothing, bedding, or sports equipment. The client with a rash should be placed in isolation for contact precautions, which involve wearing gloves and gowns and using disposable equipment.

Choice D reason: This is not the correct answer because heart palpitations are not transmitted by airborne droplets. Heart palpitations are the sensation of having a fast, irregular, or pounding heartbeat that can be caused by various factors, such as stress, anxiety, caffeine, nicotine, or heart conditions. Heart palpitations are not contagious and do not require isolation. The client with heart palpitations should be evaluated for the underlying cause and treated accordingly.

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What is the nurse's priority action for a client with compromised immunity?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?

Correct Answer is A

Explanation

This is the edited text:Which of the following clients should be placed in isolation for airborne precautions?

Correct Answer is B

Explanation

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What phase of wound healing occurs at the time of injury and lasts about 35 days?

This is the edited text:An nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. What is included in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

Dry skin (xerosis) can lead to itching (pruritus). What statement by the client indicates a need for further teaching about dry skin?