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

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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

A. Wash hands before entering the client's room
B. Take the client's vital signs every 4 hours
C. Determine whether it is temporary or permanent
D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

2. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

A. Administer antibiotics to the client
B. Increase the client's protein intake
C. Teach relaxation breathing to reduce the client's pain
D. Provide the client with anti-pyretic therapy

Correct answer: A

Rationale:

3. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

A. Traumatic injury
B. Pressure injury
C. Friction injury
D. Shearing injury

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.