Nokea
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client
- A. withdrawing from alcohol and is malnourished.
- B. receiving methylprednisolone for an asthma exacerbation.
- C. has an external urinary catheter device for urinary incontinence.
- D. receiving total parenteral nutrition (TPN) via a central line
Correct Answer: D
Rationale: TPN via a central line poses the highest infection risk due to the invasive device and nutrient-rich solution.
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The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.
The nurse is caring for a client with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would reduce this client's aspiration risk?
- A. Flush tubing with 10 mL water after feeding is completed
- B. Assess the client's gag reflex prior to feeding
- C. Assess blood glucose every 6 hours
- D. Position the client in semi-Fowler's during and after the feeding
Correct Answer: D
Rationale: Positioning the client in semi-Fowler's (30-45 degrees) during and after feeding reduces aspiration risk by using gravity to prevent gastric contents from refluxing.
The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?
- A. Keep the crutches 4 in (10 cm) in front of your feet while standing.
- B. When ascending stairs, lead with your unaffected (stronger) leg.
- C. Before sitting down in a chair, move both crutches to the unaffected (stronger) side of the body.
- D. Your shoulders should support your body weight while ambulating with crutches.
Correct Answer: B
Rationale: Leading with the stronger leg when ascending stairs ensures stability. Crutches should be 6-10 inches forward, crutches stay in both hands when sitting, and weight is on hands, not shoulders.
The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.
A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When the nurse goes to use the piece of equipment, the nurse immediately suspects it may be faulty. The nurse should take which initial action?
- A. Try the piece of electrical care equipment and see if it becomes hazardous.
- B. Call the health care provider and report your suspicion.
- C. Ask the client if they want you to try the piece of electrical care equipment.
- D. Immediately remove the piece of electrical care equipment from service.
Correct Answer: D
Rationale: Removing faulty equipment from service prevents harm, the priority action. Trying it, consulting the client, or calling the provider delays safety measures.