which client is at highest risk of compromised immunity

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. Which client is at highest risk of compromised immunity?

A. A client who just had surgery
B. A client who just delivered a baby
C. A client with extreme anxiety
D. A client who is awaiting surgery

Correct answer: A

Rationale:

2. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

A. Use a mechanical lift to reposition the client every 2 hours
B. Elevate the client's head of the bed to 45 degrees
C. Postpone daily bed bath
D. Caregiver independently slides the client up in the bed

Correct answer: A

Rationale:

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

A. The client is in a private room.
B. The client has a vase of fresh flowers on the table
C. The client has a dedicated vital signs machine
D. There is hand sanitizer by the door

Correct answer: B

Rationale:

4. What device would be best to use for a client who is immobile?

A. Standing assist device
B. A mechanical lift
C. Transfer board
D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.