Nokea
A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.
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After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.
- A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
- B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
Correct Answer: B
Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.
While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?
- A. Remove the gloves carefully and follow with hand hygiene
- B. Change gloves and continue
- C. Wash hands immediately without removing gloves
- D. Report the incident to the supervisor
Correct Answer: A
Rationale: After completing the task, the nurse should remove the gloves carefully and follow with hand hygiene. This practice is crucial to prevent the transmission of any potential pathogens, maintain cleanliness, and reduce the risk of infection. Changing gloves and continuing without proper hand hygiene may lead to contamination. Washing hands immediately without removing gloves is not recommended as it does not ensure thorough hand hygiene. Reporting the incident to the supervisor should be done if there are specific protocols in place for such incidents, but immediate hand hygiene is the priority in this scenario to ensure patient and nurse safety.
The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?
- A. Defer the bath until evening and pass on the information to the next shift.
- B. Tell the patient that daily morning baths are part of the 'normal' routine.
- C. Explain the importance of maintaining morning hygiene practices.
- D. Cancel hygiene for the day and attempt again in the morning.
Correct Answer: A
Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.
A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
- A. Allow the client to hear running water while attempting to void
- B. Provide the client with a bedpan while sitting upright
- C. Insert an indwelling urinary catheter and connect it to gravity drainage
- D. Encourage the client to limit fluid intake
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.
A healthcare professional is using the I-SBAR communication tool to provide the client's provider with information about the client. The healthcare professional should convey the client's pain status in which portion of the report?
- A. Assessment
- B. Situation
- C. Background
- D. Recommendation
Correct Answer: A
Rationale: In the I-SBAR communication tool, the 'Assessment' portion is where the healthcare professional should convey the client's pain status. This section includes the current patient information, such as the client's pain level, to provide a comprehensive view of the client's condition. Choice B ('Situation') typically involves a brief summary of the client's problem or reason for the communication. Choice C ('Background') usually covers the client's medical history and background information. Choice D ('Recommendation') focuses on the healthcare professional's suggestions or requests regarding the client's care plan, which may include pain management strategies but not the current pain status.