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. What should be done immediately after an ankle injury?

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

3. A client has AIDS. Which of these findings indicate possible infection?

Correct answer: C

Rationale:

4. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

5. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Correct answer: A

Rationale:

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