what is the nurses priority action for a client with compromised immunity
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. What is the nurse's priority action for a client with compromised immunity?

Correct answer: A

Rationale:

2. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

3. Why is traction used?

Correct answer: A

Rationale: Traction is used to help align the bones properly during the healing process. Choice A is correct because traction assists in allowing the bones to realign correctly, promoting proper healing. Choice B is incorrect as traction does not decrease the risk of misalignment; instead, it helps reduce misalignment by aiding in bone alignment. Choice C is incorrect because while traction indirectly supports wound healing by ensuring proper bone alignment, its primary purpose is not wound healing. Choice D is incorrect as the primary purpose of traction is not to allow the client to rest longer, but rather to aid in bone alignment for optimal healing.

4. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

5. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

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