a nurse is monitoring a group of clients for increased risk for developing pneumonia which of the following clients should the nurse not expect to be

ATI RN

ATI Fundamentals

1. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?

A. Client who has dysphagia
B. Client who has AIDS
C. Client who was vaccinated for pneumococcus and influenza 6 months ago
D. Client who has a closed head injury and is receiving ventilation

Correct answer: C

Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.

2. A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

A. Platelet count
B. Potassium level
C. Creatinine clearance
D. Prealbumin

Correct answer: A

Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.

3. What do high-pitched gurgles heard over the right lower quadrant indicate?

A. Increased bowel motility
B. Decreased bowel motility
C. Normal bowel sounds
D. Abdominal cramping

Correct answer: C

Rationale: High-pitched gurgles heard over the right lower quadrant indicate normal bowel sounds. Bowel sounds can vary in pitch, and high-pitched gurgles are considered normal and indicate the presence of active peristalsis in the intestines.

4. Which action would break sterile technique while preparing a sterile field for a dressing change?

A. Using sterile forceps instead of sterile gloves to handle a sterile item
B. Touching the outside wrapper of sterilized material without sterile gloves
C. Placing a sterile object at the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml) before pouring it into a sterile container

Correct answer: B

Rationale: Touching the outside wrapper of sterilized material without sterile gloves can introduce contaminants and compromise the sterility of the item. It is crucial to maintain strict adherence to sterile technique to prevent infections and ensure patient safety during procedures.

5. How can preserving skin integrity impact the circular chain of infection?

A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry

Correct answer: D

Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.