Nokea
A client in the medical-surgical unit has an indwelling urinary catheter. Which actions should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? Select all that apply.
- A. Cleanse periurethral area with antiseptics every shift
- B. Ensure each client has a separate container to empty collection bag
- C. Keep catheter bag below the level of the bladder
- D. Routinely irrigate the catheter with antimicrobial solution
- E. Use sterile technique when collecting a urine specimen
Correct Answer: B,C,E
Rationale: Using a separate container prevents cross-contamination. Keeping the bag below the bladder prevents urine backflow, reducing infection risk. E: Sterile technique minimizes pathogen introduction during specimen collection. A is incorrect as routine antiseptic cleansing can disrupt natural flora, increasing infection risk. D is incorrect as routine irrigation is not recommended unless medically indicated, as it can introduce pathogens.
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A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
- A. Client with Clostridium difficile
- B. Client with community-acquired pneumonia
- C. Client with fever of unknown origin
- D. Client with upper gastrointestinal bleed
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
The physician has ordered a minimal bacteria diet on a client with neutropenia. Which seasoning is not permitted for this client?
- A. Salt
- B. Lemon juice
- C. Pepper
- D. Ketchup
Correct Answer: C
Rationale: A minimal bacteria diet for neutropenic clients avoids foods that may harbor bacteria, such as raw or undercooked foods and certain seasonings like pepper, which can contain mold or bacteria. Salt , lemon juice , and ketchup are generally processed and less likely to pose a bacterial risk.
Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?
- A. Permission to videotape
- B. Salivary pH
- C. Mini-mental status exam
- D. Pre-anesthesia work-up
Correct Answer: D
Rationale: Pre-anesthesia work-up. ECT is delivered under general anesthesia and the client should be prepared as for any procedure involving anesthesia.
The nurse is talking with a 74-year-old client with previously well-controlled hypertension. The client currently has a blood pressure of 190/88 mm Hg and has had a cold with nasal congestion for the past 3 days. Which of the following questions would be most important for the nurse to ask?
- A. Have you received the influenza vaccine recently?
- B. Are you taking over-the-counter cold medications?
- C. Have you spent time with your grandchildren recently?
- D. Are you taking over-the-counter vitamin C supplements?
Correct Answer: B
Rationale: OTC cold medications (e.g., decongestants) can elevate blood pressure, explaining the sudden increase, making this the most important question.
A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?
- A. a report of 10 pounds weight loss in the last month
- B. a comment by the client 'I just can't sit still.'
- C. the appearance of eyeballs that appear to 'pop' out of the client's eye sockets
- D. a report of the sudden onset of irritability in the past 2 weeks
Correct Answer: C
Rationale: Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.