Nokea
A nurse is reviewing the medical records of a group of older adult clients. Which risk factor should the nurse identify as placing older adults at an increased risk for infections?
- A. Improved nutritional status
- B. Increased mobility
- C. Chronic conditions
- D. Lowered immune function
Correct Answer: D
Rationale: The correct answer is D: Lowered immune function. Older adults often experience a decline in immune function as they age, making them more vulnerable to infections. This weakened immune system can result in increased susceptibility to various pathogens. Choice A, 'Improved nutritional status,' is incorrect because good nutrition can actually help support the immune system. Choice B, 'Increased mobility,' is not directly related to an increased risk of infections. Choice C, 'Chronic conditions,' while they can contribute to a weakened immune system, do not directly address the primary risk factor for infections in older adults.
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A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?
- A. Flush the IV line with saline
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct Answer: B
Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?
- A. Apply a cold compress
- B. Discontinue the IV line
- C. Elevate the limb
- D. Increase the IV flow rate
Correct Answer: B
Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.
A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?
- A. Encourage early ambulation
- B. Provide intravenous antibiotics
- C. Apply anti-embolism stockings
- D. Place a Foley catheter to monitor output
Correct Answer: A
Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.
A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?
- A. I will soak my feet in hot water daily
- B. I will wear my slippers whenever I am out of bed
- C. I should apply lotion between my toes after washing my feet
- D. I will cut my nails in a rounded shape
Correct Answer: B
Rationale: The correct answer is B. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it helps prevent injuries to the feet, reducing the risk of infection. Choices A, C, and D are incorrect. Soaking feet in hot water daily can lead to dryness and skin damage, applying lotion between toes can create a moist environment promoting fungal growth, and cutting nails in a rounded shape can increase the risk of ingrown nails.
A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Use a special mattress for the client
- C. Keep the client on bedrest
- D. Encourage the client to remain in one position
Correct Answer: B
Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.