a nurse enters the hospital room of a client with reduced immunity what observation requires further action by the nurse
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

Correct answer: B

Rationale:

2. The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?

Correct answer: B

Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.

3. What activities should the client avoid after cataract surgery? (Select all that apply)

Correct answer: D

Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one’s nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.

4. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?

Correct answer: C

Rationale:

5. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

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