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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 : A,C,E,F

A.   The client has not received pneumococcal vaccine, which increases susceptibility to pneumococcal pneumonia.
B.   The client is oriented to time place and person which is normal.
C.   The client has not received influenza vaccine, which increases susceptibility to pneumococcal pneumonia.
D.   The client has no significant health history other than the primary concern.
E.   The client's fluid intake seems to be reduced, as indicated by their decreased urination and reports of not drinking much water due to a sore throat, which can contribute to the risk of infection.
F.   Being 70 years old increases susceptibility to respiratory infections like pneumonia.
G.   No history of smoking reduces risk compared to smokers, but is still a risk factor in pneumonia development.

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Correct Answer is ["2"]

Explanation

To administer the correct dose of penicillin G benzathine, which is 1.2 million units, and given that the available concentration is 600,000 units per mL, the nurse should calculate the volume to administer based on these values. By dividing the prescribed dose by the concentration available, the nurse can determine the volume needed for injection. In this case, 1.2 million units divided by 600,000 units per mL results in 2 mL.

A. The client stands in a tripod position prior to walking. B. The client keeps the elbows in a flexed position. C. The client pushes downward on the handgrips. D. The client places partial weight on the affected leg.

Correct Answer is D

Explanation

A. Standing in a tripod position prior to walking with crutches is a correct stance to maintain balance and stability.
B. Keeping the elbows flexed helps absorb shock during ambulation and is appropriate when using crutches.
C. Pushing downward on the handgrips is necessary to generate upward force and support while using crutches.
D. Placing partial weight on the affected leg while ambulating with crutches using a three-point gait is incorrect and can jeopardize safety by potentially causing injury or instability.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

Correct Answer is D

Explanation

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

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 has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?

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.