What is the nurse's priority action for a client with compromised immunity?
Determine whether it is temporary or permanent
Take the client's vital signs every four hours
Teach the family members to receive the flu shot annually
Wash hands before entering the client's room
The Correct Answer is D
Choice A reason: Determine whether it is temporary or permanent is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Determining whether the compromised immunity is temporary or permanent is an important assessment, but it should be done after ensuring the safety and infection prevention of the client. Compromised immunity can be temporary or permanent, depending on the cause, such as medication, disease, or genetic disorder.
Choice B reason: Take the client's vital signs every four hours is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Taking the client's vital signs every four hours is an important monitoring, but it should be done after ensuring the safety and infection prevention of the client. Vital signs can indicate the general health status and the presence of infection or inflammation, such as fever, tachycardia, or hypotension.
Choice C reason: Teach the family members to receive the flu shot annually is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Teaching the family members to receive the flu shot annually is an important education, but it should be done after ensuring the safety and infection prevention of the client. The flu shot is a vaccine that can protect the family members and the client from influenza, which can be a serious and potentially fatal infection for people with compromised immunity.
Choice D reason: Wash hands before entering the client's room is the nurse's priority action for a client with compromised immunity, because it is the most urgent and relevant. Washing hands before entering the client's room is a basic and essential infection prevention measure, which can protect the client from exposure to pathogens that can cause infection. People with compromised immunity have a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the priority assessment, but it is an important assessment for a client with a femur fracture. Pain is the unpleasant sensation that results from tissue damage or inflammation. Pain can affect the client's physical and psychological wellbeing and interfere with their recovery. The nurse should assess the client's pain level, location, quality, and duration using a valid and reliable pain scale. The nurse should also provide pain relief measures, such as medication, ice, elevation, or distraction, as ordered and as needed.
Choice B reason: This is not the priority assessment, but it is a relevant assessment for a client with a femur fracture. Medication history is the record of the drugs that the client is currently taking or has taken in the past, including prescription, overthecounter, herbal, or recreational drugs. Medication history can help the nurse identify any potential drug interactions, allergies, or contraindications that may affect the client's treatment and recovery. The nurse should ask the client about their medication history and document it accurately and completely.
Choice C reason: This is not the priority assessment, but it is a helpful assessment for a client with a femur fracture. Socioeconomic status is the measure of the client's income, education, occupation, and social class. Socioeconomic status can influence the client's access to health care, ability to afford treatment, compliance with therapy, and support system. The nurse should assess the client's socioeconomic status and provide appropriate referrals, resources, or assistance as needed.
Choice D reason: This is the priority assessment for a client with a femur fracture. Pedal pulses are the pulses that can be felt in the feet, such as the dorsalis pedis or the posterior tibial pulse. Pedal pulses can indicate the blood flow and perfusion to the lower extremities, which can be compromised by a femur fracture. A femur fracture can cause bleeding, swelling, or pressure that can reduce or obstruct the blood supply to the feet, leading to ischemia, necrosis, or gangrene. The nurse should assess the client's pedal pulses regularly and report any changes, such as absent, weak, or thready pulses. The nurse should also monitor the client's skin color, temperature, sensation, and movement in the feet.
Correct Answer is B
Explanation
Choice A reason: Providing the client with antipyretic therapy is not the nurse's priority. Antipyretic therapy is a treatment that lowers the body temperature and reduces fever. Fever is a common symptom of acute osteomyelitis, which is a bacterial infection of the bone and bone marrow. Antipyretic therapy may help to relieve the discomfort and inflammation caused by fever, but it does not address the underlying cause of the infection.
Choice B reason: Administering antibiotics to the client is the nurse's priority. Antibiotics are medications that kill or inhibit the growth of bacteria. Antibiotics are the main treatment for acute osteomyelitis, as they target the specific type of bacteria that is causing the infection. Antibiotics can prevent the spread of the infection to other bones or organs and reduce the risk of complications, such as chronic osteomyelitis, septic arthritis, or sepsis.
Choice C reason: Increasing the client's protein intake is not the nurse's priority. Protein intake is a nutritional factor that affects the wound healing and immune system. Protein is composed of amino acids, which are the building blocks of cells and tissues. Protein intake can enhance the repair and regeneration of the bone and the soft tissues that are damaged by the infection. Protein intake can also support the immune system's ability to fight off the infection. However, protein intake alone is not sufficient to treat acute osteomyelitis, as it does not eliminate the bacteria that are causing the infection.
Choice D reason: Teaching relaxation breathing to reduce the client's pain is not the nurse's priority. Relaxation breathing is a technique that involves deep and slow breathing that helps to relax the body and mind. Relaxation breathing can help to reduce the pain and stress that are associated with acute osteomyelitis. Pain is a common symptom of acute osteomyelitis, which is caused by the inflammation and pressure on the bone and the surrounding tissues. Relaxation breathing can help to ease the pain and improve the mood and quality of life of the client. However, relaxation breathing alone is not enough to treat acute osteomyelitis, as it does not address the source of the pain.
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