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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Shearing or friction is the force that caused the injury, because it occurs when the skin and underlying tissues move in opposite directions, such as when the client slides down in bed. Shearing or friction can damage the blood vessels and reduce blood flow to the skin, resulting in tissue ischemia, necrosis, and ulceration.
Choice B reason: Pressure or gravity is not the force that caused the injury, because it occurs when the skin and underlying tissues are compressed between a bony prominence and an external surface, such as when the client lies on his back. Pressure or gravity can impair blood flow and oxygen delivery to the skin, resulting in tissue damage and ulceration.
Choice C reason: Chemical or pressure is not the force that caused the injury, because it occurs when the skin is exposed to a substance that causes irritation, inflammation, or corrosion, such as when the client has a wound dressing that contains an antiseptic or a topical agent. Chemical or pressure can damage the skin barrier and increase the risk of infection and delayed wound healing.
Choice D reason: Twisting and bending is not the force that caused the injury, because it occurs when the skin and underlying tissues are stretched or distorted, such as when the client twists his ankle or bends his knee. Twisting and bending can cause sprains, strains, or tears of the ligaments, tendons, or muscles.
Correct Answer is D
Explanation
Choice A reason: The client having a butterfly rash is not a concerning finding in a client with SLE. A butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of SLE and may flare up or fade depending on the disease activity. It does not indicate any serious complication or organ damage.
Choice B reason: A blood pressure of 126/85 mm Hg is not a concerning finding in a client with SLE. This blood pressure is within the normal range and does not indicate hypertension or hypotension. Hypertension is a possible complication of SLE that may affect the kidneys, the heart, or the brain. Hypotension may indicate shock, dehydration, or infection.
Choice C reason: The client reporting chronic fatigue is not a concerning finding in a client with SLE. Chronic fatigue is a common symptom of SLE that affects the quality of life and the ability to perform daily activities. It may be caused by inflammation, pain, anemia, depression, or medication side effects. It does not indicate any acute or lifethreatening condition.
Choice D reason: A urine output of 20 mL/hour is a concerning finding in a client with SLE. This urine output is below the normal range of 30 to 50 mL/hour and indicates oliguria, which is a reduced urine production. Oliguria may indicate acute kidney injury, which is a serious complication of SLE that may lead to renal failure or death. The nurse should monitor the client's urine output, fluid balance, electrolytes, and kidney function and report any abnormal findings to the provider.
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