Nokea
The nurse is caring for a client who has just returned from surgery with a urinary catheter in place. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs)?
- A. Irrigate the catheter daily
- B. Ensure the catheter bag is always below bladder level
- C. Change the catheter every 48 hours
- D. Administer prophylactic antibiotics
Correct Answer: B
Rationale: The correct answer is to ensure the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Choice A, irrigating the catheter daily, is not recommended as it can introduce pathogens into the bladder. Changing the catheter too frequently (Choice C) can increase the risk of introducing pathogens. Administering prophylactic antibiotics (Choice D) is not the primary intervention for preventing CAUTIs and can lead to antibiotic resistance.
You may also like to solve these questions
A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?
- A. Administer antibiotics as prescribed.
- B. Encourage increased fluid intake.
- C. Perform chest physiotherapy.
- D. Provide humidified oxygen.
Correct Answer: B
Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.
A client with a diagnosis of depression is prescribed an SSRI. What is the most important information the nurse should provide?
- A. Take the medication as prescribed.
- B. Avoid consuming grapefruit juice.
- C. Report any thoughts of self-harm immediately.
- D. Understand that improvement may take weeks.
Correct Answer: C
Rationale: The most important information the nurse should provide to a client prescribed an SSRI for depression is to report any thoughts of self-harm immediately. SSRIs can increase suicidal ideation, especially at the beginning of treatment, so it is crucial to monitor for this and take appropriate actions. While it is important to take the medication as prescribed (Choice A), the immediate need for reporting self-harm ideation takes precedence. Avoiding grapefruit juice (Choice B) is a general precaution with certain medications but not as critical in this scenario. Understanding that improvement may take weeks (Choice D) is important for managing treatment expectations, but ensuring the client's safety in the context of suicidal ideation is the top priority.
In a community health setting, which individual is at highest risk for contracting an HIV infection?
- A. 17-year-old who is sexually active with numerous partners
- B. 34-year-old homosexual in a monogamous relationship
- C. 30-year-old cocaine user who inhales and smokes drugs
- D. 45-year-old who has received two blood transfusions in the past 6 months
Correct Answer: C
Rationale: The correct answer is C. Substance abuse, particularly using shared inhalation equipment like needles and pipes for drug inhalation, significantly increases the risk of contracting HIV. Choice A, the 17-year-old with multiple sexual partners, poses a risk of HIV transmission through sexual contact, but it is lower compared to the direct risk associated with sharing drug paraphernalia. Choice B, the 34-year-old homosexual in a monogamous relationship, is at lower risk since being in a monogamous relationship reduces exposure to HIV. Choice D, the 45-year-old who received blood transfusions, is also at lower risk as blood transfusions are now screened for HIV, decreasing the likelihood of transmission through this route.
The healthcare professional is developing a care plan for a client with depression. What should be included in the plan?
- A. Regular physical activity
- B. Scheduled sleep patterns
- C. Social interaction with family and friends
- D. All of the above
Correct Answer: D
Rationale: A comprehensive care plan for a client with depression should include multiple components to address various aspects of health. Regular physical activity can help improve mood and overall well-being. Scheduled sleep patterns are essential as sleep disturbances are common in depression and can worsen symptoms. Social interaction with family and friends provides emotional support and reduces feelings of isolation. Therefore, including all these aspects in the care plan can help support the client's recovery. Choice D, 'All of the above,' is the correct answer because all the options are important components of a holistic care plan for depression. Choices A, B, and C are incorrect because each of these elements plays a crucial role in managing depression.
The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?
- A. Encourage early ambulation
- B. Apply ice to the surgical site
- C. Monitor the surgical site for signs of infection
- D. Administer pain medication as prescribed
Correct Answer: A
Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.