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. What is the abbreviation for micro drop?

A. Âµgtt
B. gtt
C. mdr
D. mgts

Correct answer: A

Rationale: The correct abbreviation for micro drop is 'Âµgtt,' where the symbol 'Âµ' represents micro and 'gtt' stands for drop. Choice B, 'gtt,' is the abbreviation for drop, not specifically for micro drop. Choice C, 'mdr,' and Choice D, 'mgts,' are not standard abbreviations for micro drop and are incorrect.

3. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the healthcare professional make in the medical record?

A. Morphine 3 mg Subcutaneous every 4 hr. PRN for pain.
B. Morphine 3 mg Subcutaneous
C. Morphine 3.0 mg subcutaneously every 4 hr. PRN for pain.
D. Morphine 3 mg Subcutaneous q 4 hr. PRN for pain.

Correct answer: D

Rationale: The correct entry for documenting the prescription for morphine is 'Morphine 3 mg Subcutaneous'. This entry accurately specifies the medication, dosage, route of administration, and frequency as prescribed by the provider. Options A, C, and D contain minor errors such as missing units of measurement or incorrect abbreviations, which could lead to misinterpretation or potential medication errors. Therefore, the most appropriate and accurate choice is 'Morphine 3 mg Subcutaneous'.

4. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

5. What is the most common psychogenic disorder among elderly individuals?

A. Depression
B. Sleep disturbances (e.g., bizarre dreams)
C. Inability to concentrate
D. Decreased appetite

Correct answer: A

Rationale: Depression is the most common psychogenic disorder among elderly individuals. It can manifest as persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyed. Elderly individuals may also experience changes in appetite, sleep disturbances, and difficulty concentrating. Detecting and addressing depression in the elderly is crucial for their overall well-being and quality of life.