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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.
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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.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
- A. High calorie, low fat, low sodium
- B. High protein, low fat, low carbohydrate
- C. High protein, high calorie, unrestricted fat
- D. High carbohydrate, low protein, moderate fat
Correct Answer: C
Rationale: High protein, high calorie, unrestricted fat. The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
- A. Increase bladder tone by delaying voiding
- B. When laundering clothing, rinse several times
- C. Use plain water for the bath, shampooing hair last
- D. Have the child use antibacterial soaps while bathing
Correct Answer: C
Rationale: Use plain water for the bath, shampooing hair last. Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTIs in young girls.
A 19-year-old primigravida is admitted for observation due to a sudden increase in blood pressure. The doctor suspects a diagnosis of pregnancy-induced hypertension. Which of the following is considered a significant factor in the development of pregnancy-induced hypertension?
- A. Maternal age
- B. Nutritional status of mother
- C. Pre-pregnant weight
- D. History of hypertension
Correct Answer: D
Rationale: A history of hypertension is a significant risk factor for developing pregnancy-induced hypertension (preeclampsia), as it indicates a predisposition to vascular issues.
A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse?
- A. Encourage the parent to be involved with the child
- B. Engage in physical contact by removing the toddler's outer clothing first
- C. Have medical equipment lying on a counter within view
- D. Perform an examination in a head-to-toe order
Correct Answer: A
Rationale: Parental involvement reduces toddler anxiety during exams. Removing clothing first, visible equipment, or strict head-to-toe order may increase distress.