A hospitalized client has the following blood lab values: WBC 3,000/ul, RBC 5.0 (X 106), platelets 300, 000, what would be a priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: D

Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.

Correct Answer: D

Rationale: The correct answer is D: Check for neurologic status. This is the first action because assessing the patient's neurologic status helps identify any immediate threats to their health and guides further interventions. It is crucial to ensure the patient's safety and prioritize interventions based on their neurologic status. Starting an IV for fluids (A), getting an ECG (B), and placing a Foley catheter (C) are important interventions but should come after assessing the patient's neurologic status to address any urgent issues first.

Correct Answer: C

Rationale: The correct answer is C because it does not provide a specific, measurable outcome. It is vague and subjective, making it difficult to assess and track progress. In contrast, choices A, B, and D are all specific, measurable, and time-bound goals, making them more effective for evaluating client outcomes. Choice A specifies the amount of fluid intake and the time frame, choice B sets a clear deadline for demonstrating a skill, and choice D outlines a specific task to be completed upon discharge. Therefore, C is the correct answer as it lacks the clear criteria needed for effective outcome evaluation.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing and the type of drainage present, then will progress to more specific assessments based on the findings. This approach allows for a systematic and comprehensive evaluation of the patient's condition by moving from general observations to detailed examinations. Explanation: 1. General assessment: The nurse is initially assessing the overall appearance of the surgical dressing and the type of drainage. 2. Specific assessment: Based on the initial findings, the nurse will proceed to conduct more focused assessments, such as checking for signs of infection, monitoring vital signs, and assessing the surgical site for any complications. Other choices are incorrect: A: Gordon’s Functional Health Patterns - This framework focuses on assessing different aspects of an individual's health patterns, such as activity level, sleep patterns, and coping mechanisms. It is not the most appropriate approach in this situation. B: Activity-exercise pattern assessment - This type of assessment focuses

Correct Answer: C

Rationale: The correct answer is C: Taking a walk outside. Patients with lymphoma have weakened immune systems, making them more susceptible to infections. Walking outside exposes them to various environmental pathogens, increasing the risk of infection. Going to church (A) and cleaning the house (B) can be done in controlled environments, while watching television (D) does not involve exposure to external pathogens like going for a walk outside does. Therefore, taking a walk outside poses the highest risk for infection among the given activities.

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

Correct Answer: A

Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension. Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.

Correct Answer: B

Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (C) and compromised circulation (D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.