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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 D

Explanation

A. Notifying the provider is necessary but not the first action.
B. Applying a cold pack may help with swelling but is not the first action to take.
C. Removing the PICC line should only be done after assessing the situation and consulting with the provider.
D. Measuring the circumference of both upper arms is the first action to assess the extent of the swelling and compare it to the other arm, which will help determine the severity of the issue.

A. A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode B. A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800 C. A client who was admitted for chest pain and is reporting a new onset of indigestion D. A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400

Correct Answer is C

Explanation

A. A blood glucose reading of 70 mg/dL is low but stable, and the client has already received treatment.
B. Pulling out a peripheral IV catheter is concerning but not immediately life-threatening.
C. New onset of indigestion in a client admitted for chest pain could indicate a cardiac event and requires immediate assessment.
D. A temperature of 38.9°C (102°F) in a client with pneumonia needs monitoring but is not as urgent as potential cardiac issues.

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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

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is C

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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.