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A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
- A. Encouraging the client to consume a high-protein diet
- B. Performing hand hygiene before, during, and after direct contact with the client
- C. Placing the client in a room with positive-pressure airflow
- D. Changing the client's bed linens each day
Correct Answer: B
Rationale: Correct Answer: B - Performing hand hygiene before, during, and after direct contact with the client
Rationale: Hand hygiene is a crucial infection control measure to prevent the transmission of infections. By washing hands before, during, and after contact with the client, the nurse reduces the risk of spreading the infection to themselves or other individuals. It helps to eliminate pathogens that may be present on the hands and prevents cross-contamination. This practice is supported by evidence-based guidelines and is a fundamental aspect of infection prevention in healthcare settings.
Summary of Incorrect Choices:
A: Encouraging a high-protein diet is important for the client's nutrition but does not directly prevent the transmission of the infection.
C: Placing the client in a room with positive-pressure airflow may be suitable for specific conditions but does not address the immediate need for infection prevention.
D: Changing the client's bed linens each day is essential for maintaining cleanliness but does not directly prevent the transmission of the infection.
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A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
- A. I will clean and dry the area before applying the patch.
- B. I will use lotion on irritated skin before applying a new patch in that area.
- C. I will remove the old patch and apply a new one in the same location.
- D. I will press the patch securely in place on my forearm.
Correct Answer: A
Rationale: The correct answer is A: "I will clean and dry the area before applying the patch." This is the correct answer because cleaning and drying the skin before applying the transdermal patch helps ensure proper adhesion and absorption of the medication. Moist or oily skin can prevent the patch from sticking effectively and may interfere with drug absorption.
Choice B is incorrect because using lotion on irritated skin may decrease the adhesion of the patch. Choice C is incorrect because it is important to rotate patch sites to prevent skin irritation and improve drug absorption. Choice D is incorrect because pressing the patch securely in place is important, but not the only step necessary for proper application.
A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?
- A. Fill out an occurrence form.
- B. Administer the medication to the correct client.
- C. Notify the client's provider.
- D. Check the client's vital signs.
Correct Answer: D
Rationale: The correct answer is D: Check the client's vital signs. The first action the nurse should take is to assess the client's vital signs to monitor for any potential adverse effects of the medication. Nifedipine is a calcium channel blocker that can cause hypotension and other cardiovascular effects. By checking the vital signs first, the nurse can promptly identify any signs of distress and take immediate action to ensure the client's safety. This step is crucial in prioritizing the client's well-being and addressing any potential harm caused by the medication error.
Summary:
A: Filling out an occurrence form can be done later but is not the immediate priority.
B: Administering the medication to the correct client is not appropriate as it may cause harm.
C: Notifying the client's provider is important but not as urgent as assessing the client's vital signs.
D: Checking the client's vital signs is the first and most critical step to ensure client safety.
A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
- A. Dehydration
- B. Rigid abdomen
- C. Decreased bowel sounds
- D. Hypothermia
Correct Answer: A
Rationale: The correct answer is A: Dehydration. Diarrhea can lead to fluid and electrolyte loss, causing dehydration. The nurse should expect signs such as increased thirst, dry mouth, decreased urine output, and low blood pressure. Rigid abdomen (B) is more indicative of a surgical emergency like peritonitis. Decreased bowel sounds (C) may occur in diarrhea but are not as concerning as dehydration. Hypothermia (D) is not a typical finding in diarrhea.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
- A. Mix the three medications together prior to administering.
- B. Flush the NG feeding tube with 30 mL of water immediately following medication administration.
- C. Dilute each medication with 10 mL of tap water.
- D. Maintain the head of the bed in a flat position for 30 min following medication administration.
Correct Answer: B
Rationale: The correct answer is B, which instructs the nurse to flush the NG feeding tube with 30 mL of water immediately following medication administration. This action helps ensure that the medications are properly delivered through the feeding tube and into the stomach. Flushing the tube with water helps prevent any medication residue from clogging the tube and ensures that the medications are fully administered to the client.
Option A is incorrect because mixing the medications together could alter their effectiveness or cause potential interactions. Option C is incorrect as diluting the medications with tap water may affect their potency or stability. Option D is incorrect because maintaining the head of the bed flat for 30 minutes following medication administration is not necessary for enteral feedings.
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
- A. Determine the location of the pain.
- B. Reposition the client.
- C. Administer the medication.
- D. Review the effects of the pain medication.
Correct Answer: A
Rationale: The correct answer is A: Determine the location of the pain. This is the first step because assessing the location of pain is crucial in understanding the client's condition and choosing the appropriate medication. Identifying the source of pain helps in selecting the most effective treatment. Repositioning the client (B) or administering medication (C) should only be done after the nurse assesses the pain location. Reviewing the effects of the pain medication (D) is important but not the first step. Other choices are not relevant to the initial assessment of the client's pain.