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. The nurse is performing a psychosocial assessment on a client with a severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?

A. "Tell me about what medication you are taking"?
B. "What physical limitations are you experiencing?"?
C. "How does this impact your role in your family?"?
D. "What therapies are you using to reduce swelling?"?

Correct answer: C

Rationale:

3. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.

4. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?

A. Tell the client’s family that they will be expected to stay overnight
B. Apply restraints to the client
C. Shout to the client
D. Orient the client to the location of objects in the room

Correct answer: D

Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.