A nurse is teaching a client who is immunocompromised and requires a protective environment. Which of the following statements should the nurse make?

"You should wear a sterile gown when outside of your room."

"You'll share a room with a client who is also immunocompromised."

"You are required to wear an N95 respirator mask."

"You will be placed in a positive-pressure airflow room."

Answer and Explanation

The Correct Answer is D

A. "You should wear a sterile gown when outside of your room." While protective clothing may be required in certain cases, wearing a sterile gown outside the room is not a standard recommendation for immunocompromised clients.
B. "You'll share a room with a client who is also immunocompromised." Clients who require a protective environment should be placed in a private room to minimize the risk of exposure to infections.
C. "You are required to wear an N95 respirator mask." N95 respirators are typically required for healthcare workers caring for clients with airborne precautions, not for immunocompromised clients in a protective environment.
D. "You will be placed in a positive-pressure airflow room." A positive-pressure room helps keep airborne pathogens out by ensuring that air flows out of the room rather than into it, reducing the risk of infections.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

Client 3 – Pulmonary Edema (Airway/Breathing concern)
2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)

A. The client cannot change their mind after signing consent. B. The alternative treatments to the procedure should be explained. C. The time of the procedure should be indicated on the form. D. The charge nurse should review the form once it's signed.

Correct Answer is B

Explanation

A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.

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A nurse is teaching a client who is immunocompromised and requires a protective environment. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a medical-surgical unit is caring for 6 clients. Exhibits Complete the following sentence by using the lists of options. The first client the nurse should assess is dropdownfollowed bydropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale:

Priority Order (Using ABCs & Maslow’s Hierarchy):

A nurse is teaching a group of students about the components of informed consent. Which of the following should the nurse include?

Correct Answer is B

Explanation

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