which factor places a patient at the highest risk for infection

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. Which factor places a patient at the highest risk for infection?

A. A healthy immune system
B. Presence of chronic illness
C. Being well-nourished
D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

2. A client is being prepared for discharge after a stroke. Which of the following interventions should be included in the discharge plan to prevent complications?

A. Recommend physical therapy to improve mobility
B. Teach the client how to use an incentive spirometer
C. Encourage the client to ambulate daily
D. Provide education on proper medication management

Correct answer: D

Rationale: The correct answer is to provide education on proper medication management. Proper medication management is crucial in reducing the risk of stroke recurrence and ensuring the client adheres to the treatment plan. While physical therapy, incentive spirometer use, and daily ambulation are important aspects of stroke rehabilitation, they are not directly related to preventing complications during the discharge phase.

3. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?

A. White blood cell count (WBC)
B. C-reactive protein (CRP)
C. Erythrocyte sedimentation rate (ESR)
D. Hemoglobin and hematocrit levels

Correct answer: A

Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.

4. What is the most appropriate method for assessing a patient's pain level?

A. Observe the patient's facial expressions.
B. Use a standardized pain scale, such as 0-10.
C. Ask the patient to rate their pain based on their mood.
D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

5. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

A. Loud volume of the television set
B. Wall-to-wall carpet in the living room
C. Low chairs without armrests
D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.