The nurse is providing care for the following patients. Which patient is at highest risk of developing an infection?
46-year-old with a low neutrophil count
59-year-old seven days post abdominal surgery
82-year-old with a history of leukemia ten years ago
62-year-old on antibiotic therapy
The Correct Answer is A
A. 46-year-old with a low neutrophil count: Neutrophils are essential for fighting infection. A low neutrophil count (neutropenia) significantly increases infection risk, making this the highest-priority patient.
B. 59-year-old seven days post abdominal surgery: While postoperative patients are at risk for infection, the greatest risk is within the first few days after surgery. By day seven, the risk decreases if no signs of infection are present.
C. 82-year-old with a history of leukemia ten years ago: While leukemia can affect the immune system, a history of leukemia from ten years ago is less concerning than an active condition causing immunosuppression.
D. 62-year-old on antibiotic therapy: While antibiotics can disrupt normal flora and increase the risk of infections like Clostridioides difficile, this risk is lower than that of a patient with neutropenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inspect the patient's feet for a diabetic ulcer: Patients with obesity are at increased risk for skin breakdown, and foot ulcers may go unnoticed. Early detection prevents complications.
B. Expose the full body to ensure efficiency: Patients should be kept covered as much as possible to maintain dignity, privacy, and body temperature.
C. Encourage the patient to provide self-care: If the patient is able, self-care promotes independence and helps maintain mobility.
D. Apply baby powder to the perineal area and skin folds: Powder can clump and retain moisture, leading to skin irritation and fungal infections, especially in skin folds.
Correct Answer is C
Explanation
A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.
B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.
C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.
D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.
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