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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. 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.

A. Implement a recorded order message if the nurse can hear and understand it clearly. B. Transcribe the order into the client's health record. C. Repeat the order back to the provider. D. Question any part of the order that is unclear or inappropriate. E. Obtain the provider's signature within 8 hr.

Correct Answer is ["B","C","D"]

Explanation

A. Implementing a recorded order message is not a standard practice and may not be permissible in all healthcare settings.
B. Transcribing the order into the client's health record is essential to ensure accurate documentation.
C. Repeating the order back to the provider ensures that the nurse has correctly understood the prescription.
D. Questioning any part of the order that is unclear or inappropriate ensures patient safety and accuracy.
E. While obtaining the provider's signature is necessary, the timeframe may vary depending on facility policies and regulations. The focus should be on ensuring the accuracy and clarity of the order first.

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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 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 receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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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.