Nokea
A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
- A. Chlorhexidine washes
- B. Urinary catheterization
- C. Malnutrition
- D. Multiple caregivers
Correct Answer: B
Rationale: The correct answer is B: Urinary catheterization. This is a common cause of HAIs due to the introduction of bacteria into the urinary tract. Catheters provide a direct pathway for bacteria to enter the body, leading to infections such as urinary tract infections. The other choices are incorrect because:
A: Chlorhexidine washes are actually used to prevent infections by killing bacteria on the skin.
C: Malnutrition can weaken the immune system and make individuals more susceptible to infections, but it is not a direct cause of HAIs.
D: Multiple caregivers can increase the risk of infections if proper hygiene practices are not followed, but it is not a specific cause of HAIs like urinary catheterization.
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A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?
- A. At the beginning of the collection time, urinate and then discard the urine.
- B. Keep the collection container at room temperature.
- C. Save each urine collection in a separate container.
- D. At the end of the collection time, urinate and save the urine in a separate container.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Urinating and discarding the first urine sample helps ensure that the 24-hour collection period begins accurately. This initial voiding clears out any urine that has been in the bladder prior to the start of the collection. This step is crucial to obtain an accurate measurement of substances excreted over the 24-hour period.
Summary:
B: Keeping the collection container at room temperature is not crucial for accurate urine collection.
C: Saving each urine collection in a separate container may lead to inaccuracies in the final analysis.
D: Urinating and saving the final urine sample separately at the end of the collection period may skew the results.
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)
- A. Shallow respirations
- B. Cardiac dysrhythmias
- C. Flushing
- D. Hyperactive reflexes
- E. Abdominal pain
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Shallow respirations (A) occur as a compensatory mechanism to retain CO2 and decrease pH. Cardiac dysrhythmias (B) can result from electrolyte imbalances associated with alkalosis. Hyperactive reflexes (D) are a sign of neuromuscular irritability due to altered electrolyte levels. Flushing (C) and abdominal pain (E) are not typically associated with metabolic alkalosis. In summary, the nurse should monitor for shallow respirations, cardiac dysrhythmias, and hyperactive reflexes in a client with metabolic alkalosis, as they are indicative of the condition and its complications.
A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?
- A. Weak pulse
- B. Bradycardia
- C. Hypertension
- D. Distended neck veins
Correct Answer: A
Rationale: A weak, thready pulse is a classic sign of hypovolemia. Bradycardia and hypertension are more common with fluid overload.
A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?
- A. Assist the guest to the floor and begin mouth-to-mouth resuscitation.
- B. Observe the guest before taking further action.
- C. Perform the Heimlich maneuver on the guest.
- D. Slap the guest on the back several times.
Correct Answer: C
Rationale: The correct answer is C: Perform the Heimlich maneuver on the guest. This is the appropriate action for a choking individual who is unable to speak or breathe. The Heimlich maneuver helps dislodge the obstruction from the airway by applying abdominal thrusts. It is crucial to act quickly in such situations to prevent further complications like loss of consciousness or asphyxiation.
Choice A is incorrect as mouth-to-mouth resuscitation is not appropriate for a choking victim. Choice B is incorrect as observing without taking immediate action can be dangerous if the individual's airway is completely blocked. Choice D is incorrect as slapping the back may not effectively dislodge the obstruction. It is essential to prioritize the Heimlich maneuver to clear the airway and restore breathing.
A nurse is caring for a client who follows Halal, Islamic dietary laws. The nurse should recognize that the client will practice which of the following dietary practices?
- A. Does not eat meat and dairy products at the same meal.
- B. Does not eat birds of prey.
- C. Refrains from eating snacks between meals.
- D. Does not eat shellfish.
Correct Answer: B
Rationale: Halal dietary laws prohibit the consumption of birds of prey, as they are considered impure.