The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. Which of the following should be included in these instructions?
1. cloudy urine
2. increased sputum production
3. purulent wound drainage
4. irritated oral mucosa
4
Rationale: The immunocompromised patient will not demonstrate a normal immune response so clinical findings will be different. These patients will not be able to form pus so common infection findings such as cloudy urine, increased sputum production and purulent wound draining will not occur. Monitoring for infection should focus on the mucous membranes, skin, and lungs, which are the most common sites of infection in this patient population. The nurse should instruct the patient to suspect irritated oral mucosa as a sign of infection.
You might also like to view...
The nurse is caring for a patient with a large wound on the right hip. What nursing measure is the most essential for the patient?
1. Keep the patient on continuous bed rest. 2. Encourage the patient to sit up in a chair as much as possible through the day. 3. Turn the patient from side to side every 2 hours. 4. Keep the patient's weight off the right side.
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).
A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration?
1. Rest and exercise 2. Adjusting to physiologic changes and limitations 3. High obesity percentages 4. Safety promotion and injury prevention
The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority?
1. Inventory of clothes and other personal belongings 2. Orientation to the nursing unit and individual room 3. Interview regarding medications currently being taken 4. Assessment of body systems for presurgery checklist