what is the nurses priority action for a client with compromised immunity

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. What is the nurse's priority action for a client with compromised immunity?

A. Wash hands before entering the client's room
B. Take the client's vital signs every 4 hours
C. Determine whether it is temporary or permanent
D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

2. How many mg is 5000 mcg? (Type answer as numeric only)

A. 5
B. 6
C. 4
D. 3

Correct answer: A

Rationale: 5000 mcg is equal to 5 mg.

3. A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation of the neurovascular status of the client's affected extremity?

A. Color
B. Temperature
C. Sensation
D. Skin integrity

Correct answer: D

Rationale:

4. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?

A. Once retinal detachment occurs, it does not return to its normal state
B. Once the tissue has necrosed from high-pressure, it does not regenerate
C. Glaucoma always leads to permanent blindness
D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.