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A nurse is caring for a client.

Medication Administration Record:

Budesonide 6 mg PO daily.

Laboratory Results:

Hematocrit (Hct): 47% (Normal range: 37% to 52%)

Hemoglobin (Hgb): 16 g/dL (Normal range: 12 to 18 g/dL)

Potassium: 3.6 mEq/L (Normal range: 3.5 to 5.0 mEq/L)

History and Physical:

BMI: 16 (Reference Range:18.5 - 24.9)

History of type 2 diabetes mellitus.

Nonsmoker.

New diagnosis of Crohn's disease.

Click to highlight the findings that increase the client's susceptibility to infection.

To deselect a finding, click on the finding again.

Budesonide 6 mg PO daily

BMI: 16

History of type 2 diabetes mellitus

New diagnosis of Crohn's disease

Hematocrit (Hct): 47%

Hemoglobin (Hgb): 16 g/dL

Potassium: 3.6 mEq/L

Answer and Explanation

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

Findings that Could Increase Susceptibility to Infection:

Budesonide 6 mg PO daily:
- Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.
BMI of 16:
- Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.
History of Type 2 Diabetes Mellitus:
- Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.
New Diagnosis of Crohn's Disease:
- Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.

Findings That Do Not Increase Susceptibility to Infection:

Hematocrit (Hct) of 47%:
- Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.
Hemoglobin (Hgb) of 16 g/dL:
- Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.
Potassium level of 3.6 mEq/L:
- Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.

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Correct Answer is D

Explanation

Choice A rationale:

Justice is the ethical principle related to fairness and equality in healthcare. It is not applicable in this scenario as it does not address the nurse's action of returning at 1400 for wound care.

Choice B rationale:

Autonomy is the principle that respects a patient's right to make decisions about their own healthcare. While important, this is not the focus of the nurse's action in this scenario.

Choice C rationale:

Veracity refers to truthfulness and honesty in healthcare. The nurse returning at the agreed time of 1400 does not primarily relate to veracity. It is more about keeping a commitment.

Choice D rationale:

Fidelity, or faithfulness, is the ethical principle that the nurse is demonstrating in this scenario. The nurse is keeping their commitment to provide wound care at the agreed time of 1400. This aligns with the principle of fidelity.

A. Providing tracheostomy care for a client. B. Assessing a client who just returned from surgery. C. Teaching a client who is preoperative how to use an incentive spirometer. D. Obtaining a blood pressure for a client who is to be discharged later in the day.

Correct Answer is D

Explanation

The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.

Choice A rationale:

Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).

Choice B rationale:

Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.

Choice C rationale:

Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.

Choice D rationale:

Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.

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Findings that Could Increase Susceptibility to Infection:

Findings That Do Not Increase Susceptibility to Infection:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is desiring their wound care to be provided at 1400.The nurse returns at 1400 to perform wound care for the client.Which of the following ethical principles is the nurse demonstrating?

Correct Answer is D

Explanation

A nurse is planning care for clients. Which of the following tasks can the nurse delegate to an assistive personnel (AP)?

Correct Answer is D

Explanation

A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include?

A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client's health record.Which of the following information should the nurse include?

A nurse is creating a teaching plan for a client who has a new diagnosis of diabetes mellitus. Exhibits Which of the following teaching methods is based on the cognitive domain of learning? Select all that apply.

A nurse is preparing to provide education to a client about the Affordable Care Act (ACA). Which of the following information should the nurse include?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

A nurse is preparing an in-service about communication for a group of staff nurses.Which of the following information should the nurse include when discussing the electronic mode of communication?

A nurse is teaching a newly licensed nurse about palliative care. Which of the following information should the nurse include?

An acute care nurse is caring for a client who is postoperative and has a prescription for physical therapy 2-3 times per day for 2 weeks.Which of the following resources should the nurse anticipate that the client will require upon discharge?