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A nurse in an emergency department (ED) is admitting a client.
Exhibits
Select 4 findings in the client's medical record that place them at risk for pneumonia.

Pneumococcal vaccine

Level of consciousness

Influenza vaccine

Health history

Fluid intake

Age

Smoking history

Answer and Explanation

Correct Answer : B,D,E,F

A. Pneumococcal vaccine → Not having it increases risk, but the option itself (“Pneumococcal vaccine”) is misleading; risk comes from lack of vaccine, not its presence.

B. Level of consciousness → Client is lethargic and has difficulty answering questions, which can increase risk of aspiration and reduce effective airway clearance.

C. Influenza vaccine → Similarly, not getting the vaccine is a risk, but the option is phrased as “Influenza vaccine,” which is protective, not a risk factor.

D. Health history → Lack of pneumococcal and influenza vaccinations increases susceptibility to respiratory infections.

E. Fluid intake → Client reports reduced fluid intake, leading to thickened secretions, impaired mucociliary clearance, and higher risk of pneumonia.

F. Age → Middle-aged and older adults are at higher risk for pneumonia due to decreased physiologic reserve.

G. Smoking history → Smoking history is incorrect. While a history of smoking, or exposure to second-hand smoke, increases a client’s risk of contracting community-acquired pneumonia, the client reports no smoking history.

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Correct Answer is D

Explanation

A. Driving the client to the emergency department is not appropriate when the client is experiencing symptoms of a potential stroke; immediate medical assessment is needed.
B. Obtaining the telephone number of the client's provider does not address the immediate need for emergency medical care.
C. Finding a location for the client to sit does not address the urgency of the situation; prompt medical attention is crucial.
D. Calling emergency services is the correct action to ensure the woman receives timely medical care for stroke symptoms.

A. Stage 1 hypertension B. Elevated C. Stage 2 hypertension D. Within the expected reference range

Correct Answer is B

Explanation

A. Stage 1 hypertension is defined as a systolic BP of 130-139 mm Hg or a diastolic BP of 80-89 mm Hg.
B. Elevated BP is defined as a systolic BP of 120-129 mm Hg and a diastolic BP of less than 80 mm Hg.
C. Stage 2 hypertension is defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher.
D. Normal BP is defined as a systolic BP of less than 120 mm Hg and a diastolic BP of less than 80 mm Hg.

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A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

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A nurse in an emergency department (ED) is admitting a client.
Exhibits
Select 4 findings in the client's medical record that place them at risk for pneumonia.