A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?- Nurselytic

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Multi Dimensional Care | Exam | Rasmusson Questions

Question 1 of 5

A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

A. The client is in a private room. B. The client has a vase of fresh flowers on the table C. The client has a dedicated vital signs machine D. There is hand sanitizer by the door

Correct Answer: B

Rationale:

Question 2 of 5

A client is recovering from a fractured radius that occurred 7weeks ago. Which state of bone healing occurs at this time as the callus is restored and transformed into bone?

A. Stage 3 B. Stage 5 C. Stage 1 D. Stage 4

Correct Answer: D

Rationale:

Question 3 of 5

The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

A. Offer the client protein with meals to promote healing B. Remove the old dressing with clean gloves C. Teach the client about nonpharmacological pain control methods D. Check medication administration record (MAR)for as needed orders (PRN)

Correct Answer: C

Rationale:

Question 4 of 5

The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

A. Remove the nursing diagnosis in the plan of care since it has not occurred B. Change the nursing diagnosis in plan of care to impaired mobility C. Modify the nursing diagnosis in plan of care to impaired skin integrity D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct Answer: D

Rationale:

Question 5 of 5

The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

A. The client refused her pain medication this morning and is doing physical therapy. B. The client reports a minor headache and states she takes an over-the-counter pain pill at home. C. The client reports intermittent flatus and minor abdominal discomfort. D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct Answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

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