Nokea
A nurse is caring for a hospitalized patientwith a urinary catheter. Which nursing actionbestprevents the patient from acquiring an infection?
- A. Maintaining a closed urinary drainage system
- B. Inserting the catheter using strict clean technique
- C. Disconnecting and replacing the catheter drainage bag once per shift
- D. Fully inflating the catheter’s balloon according to the manufacturer’s recommendation
Correct Answer: A
Rationale: The correct answer is A: Maintaining a closed urinary drainage system. This action prevents infection by reducing exposure to external pathogens. Step 1: A closed system minimizes the risk of contamination. Step 2: It prevents entry of bacteria into the urinary tract. Step 3: Regularly emptying the drainage bag helps maintain a closed system. Step 4: This action promotes patient safety and reduces infection risk. Summary: Choice B (strict clean technique) may reduce infection risk during catheter insertion but does not prevent infections post-insertion. Choice C (replacing drainage bag once per shift) increases infection risk due to frequent disconnection. Choice D (fully inflating catheter balloon) is unrelated to infection prevention.
You may also like to solve these questions
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
- A. Modified radical mastectomies are very hard on a patient, both physically and emotionally and they really arent necessary anymore.
- B. According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial.
- C. Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence.
- D. According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer.
2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy.
3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer.
4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal.
5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
- A. Vertigo
- B. Tinnitus
- C. Nystagmus
- D. Astigmatism
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient’s magnesium level is 6 mg/dL. What is the nurse’s priority action?
- A. Stop the infusion of magnesium.
- B. Assess the patient’s respiratory rate.
- C. Assess the patient’s deep tendon reflexes.
- D. Notify the health care provider of the magnesium level.
Correct Answer: A
Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.
A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy?
- A. A patient 35 years old
- B. A patient 68 years old
- C. A patient with a college degree
- D. A patient with a high-school diploma
Correct Answer: D
Rationale: The correct answer is D because patients with lower health literacy, such as those with a high-school diploma, may struggle to understand complex health information. The nurse should assess this patient closely to ensure they comprehend and can follow instructions. Patients with higher education levels (college degree) may have better health literacy skills. Age alone (35 or 68 years old) does not determine health literacy level. It is essential to focus on the patient's educational background to assess their health literacy effectively.
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
- A. Risk factors for postoperative cytomegalovirus (CMV)
- B. Compensating for vision loss for the next several weeks
- C. Non-pharmacologic pain management strategies
- D. Signs and symptoms of increased intraocular pressure
Correct Answer: B
Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment.
A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation.
C: Non-pharmacologic pain management is important but not the priority compared to vision loss.
D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.