a nurse is providing oral hygiene for an unconscious client what is the priority nursing intervention

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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

A. Position the client on one side with the head turned towards you
B. Handle dentures with care
C. Use gentle brushing and flossing techniques for clients with fragile mucosa
D. Have a suction apparatus ready at the bedside

Correct answer: A

Rationale:

2. 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.

3. Most adults with human immunodeficiency virus will exhibit which of the following laboratory values?

A. Higher than normal number of CD4+ T-cells and CD8+ T-cells are normal
B. Lower than normal number of CD4+ T-cells and higher than normal CD8+ T-cells
C. Higher than normal number of CD4+ T-cells and CD8+ T-cells are low
D. Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal

Correct answer: D

Rationale:

4. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.