a nurse enters the hospital room of a client with reduced immunity what observation requires further action by the nurse
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

Correct answer: B

Rationale:

2. The client had surgery one day ago. What assessment is most likely related to pain?

Correct answer: A

Rationale:

3. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.

4. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

Correct answer: D

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

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