Author Question: The nurse is orienting a new graduate as they care for their assigned clients. The nurse asks the ... (Read 66 times)

jc611 · **on:** Jul 22, 2018

The nurse is orienting a new graduate as they care for their assigned clients. The nurse asks the graduate to prioritize care for these clients based on their risk for infection.

Which of the following clients would be most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain
2. A 19-year-old woman in her first trimester of pregnancy
3. A 72-year-old male client with COPD
4. An 86-year-old female client on steroid therapy

Question 2

A client comes into the emergency department with a detached retina. Which of the following nursing diagnoses would be a priority for this client?

1. Risk for Infection
2. Ineffective Tissue Perfusion: Retinal
3. Ineffective Coping
4. Anxiety

kaylee05 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4. An 86-year-old female client on steroid therapy

Rationale:
The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system. A client in the emergency department with abdominal pain has just arrived in the facility, and not enough time has elapsed for this client to be considered to have a nosocomial infection. If this client has an infection, it would be community acquired. The 19-year-old female who is pregnant is at a low risk. The 72-year-old male with COPD is at a higher risk for infection than the 19-year-old due to his age and chronic respiratory condition, but the 86-year-old is older and has a weakened immune system because of taking steroids.

Answer to Question 2

2. Ineffective Tissue Perfusion: Retinal

Rationale:
Immediate intervention is required for a client with a detached retina to ensure effective tissue perfusion and preserve vision. The priority nursing diagnosis for the client would be ineffective tissue perfusion: retinal. The client will most likely demonstrate anxiety with the loss of vision; however, retinal tissue perfusion is the priority. Risk for infection and ineffective coping would not be priorities at the time of presenting to the emergency department with a detached retina.