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

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?

A. The client is in a private room.
B. The client has a vase of fresh flowers on the table
C. The client has a dedicated vital signs machine
D. There is hand sanitizer by the door

Correct answer: B

Rationale:

2. The nurse is caring for 4 clients. What client should the nurse see first?

A. A client with multiple children visiting
B. A client with lupus asking for dinner
C. A client on Methotrexate with a fever
D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.

3. A client has a new arm cast. What is incorrect teaching by the nurse?

A. Use a sling to alleviate fatigue
B. Elevate the arm above the heart to reduce swelling
C. Report â€˜hot spotsâ€™ felt under the cast
D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

4. A client with a diagnosis of Human Immunodeficiency Virus develops pneumonia. What type of infection is this?

A. An opportunistic infection
B. A root cause infection
C. A pathogenic infection
D. A nosocomial infection

Correct answer: A

Rationale: The correct answer is A: An opportunistic infection. In patients with Human Immunodeficiency Virus (HIV), infections like pneumonia are considered opportunistic because they take advantage of a weakened immune system. Option B, root cause infection, is incorrect as it does not describe the nature of the infection in relation to the patient's condition. Option C, pathogenic infection, is incorrect because while pneumonia is caused by pathogens, in the context of HIV, it is specifically termed as an opportunistic infection. Option D, nosocomial infection, is also incorrect as it refers to infections acquired in a healthcare setting, not related to the patient's HIV status.