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A client with an infection has a fever. What actions by the nurse help increase the client's comfort?
- A. Administer antipyretics around the clock.
- B. Change the client's gown and linens when damp.
- C. Offer cool fluids to the client frequently.
- D. Place ice bags in the warm areas.
- E. Provide a fan to help cool the client.
Correct Answer: B,C
Rationale: Comfort measures appropriate for this client include offering frequent cool drinks and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.
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A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Elevate the arm above the level of the heart.
- B. Use a fan to help cool the client if feverish.
- C. Place cool, wet cloths on top of the wound.
- D. Take the client's temperature.
Correct Answer: A
Rationale: Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Placing a cool, wet cloth on the wound may macerate the broken skin. Taking the client's temperature provides data but does not increase comfort.
A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is most important?
- A. Monitor for signs of neurological deterioration.
- B. Administer antipyretics to reduce fever.
- C. Place the client in droplet precautions.
- D. Obtain a lumbar puncture for CSF analysis.
Correct Answer: C
Rationale: Since meningitis is suspected, placing the client in droplet precautions is critical to prevent the spread of infection, especially if it is caused by pathogens like Neisseria meningitidis. Monitoring for neurological deterioration and obtaining a lumbar puncture are important but secondary to initiating precautions. Administering antipyretics addresses symptoms but not the spread of infection.
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager should reduce the number of infections?
- A. Auditing staff members hand hygiene practices
- B. Ensuring clients are placed in appropriate isolation
- C. Establishing a policy to treat urinary infections quickly
- D. Teaching staff members about infection control methods
Correct Answer: A
Rationale: All methods will help prevent infection; however, health care workers' lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection.
- A. Colonization by host bacteria
- B. Gastrointestinal secretions
- C. Inflammatory processes
- D. Skin and mucous membranes
Correct Answer: D
Rationale: The skin and mucous membranes are the most important barrier against infection because they provide a physical and chemical barrier that prevents pathogens from entering the body. The other options are also barriers, but are considered secondary to skin and mucous membranes.
A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to reduce the number of infections. The answer is?
- A. It mechanically removes biofilm on teeth.
- B. It is easier to clean all surfaces with a brush.
- C. Oral care is important to all care clients.
- D. Toothbrushes last longer than oral swabs.
Correct Answer: A
Rationale: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.