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. If a patient's blood pressure is 150/96, what is his pulse pressure?

A. 54
B. 96
C. 150
D. 246

Correct answer: A

Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.

3. A client requests the creation of a living will. Which of the following actions should the nurse take?

A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client's understanding of life-sustaining measures.
C. Determine the client's preferences about post-mortem care.
D. Request a conference with the client's family

Correct answer: B

Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.

4. When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?

A. Administer antibiotics
B. Provide supplemental oxygen
C. Administer antiviral medications
D. Administer bronchodilators

Correct answer: A

Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.

5. Which of the following vascular system changes result from aging?

A. Increased peripheral resistance of the blood vessels
B. Decreased blood flow
C. Increased workload of the left ventricle
D. All of the above

Correct answer: D

Rationale: As individuals age, various changes occur in the vascular system. These changes include increased peripheral resistance of the blood vessels, decreased blood flow, and an increased workload of the left ventricle. Therefore, all the listed changes result from aging, making option D, 'All of the above,' the correct answer.