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. Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?

A. Reflex sympathetic dystrophy
B. Avascular necrosis
C. Delayed union
D. Complex regional pain syndrome

Correct answer: B

Rationale: The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.

3. When providing a routine bed bath, what action does the nurse complete first?

A. Cleanse the client's feet
B. Cleanse the client's hands
C. Cleanse the client's perineal area
D. Cleanse the client's face

Correct answer: D

Rationale:

4. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?

A. Ischial tuberosity
B. Compartment syndrome
C. Broken arm syndrome
D. Pulmonary embolism

Correct answer: B

Rationale:

5. A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?

A. Ultrasonic imaging
B. Gonioscopy
C. Corneal staining
D. Electroretinography

Correct answer: B

Rationale: Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.