Nokea
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.
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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.
Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
- A. Assessing skin and mucous membranes
- B. Consistently using appropriate hand hygiene
- C. Administering antibiotics promptly
- D. Teaching visitors not to visit if they are ill
Correct Answer: B
Rationale: Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members' contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly, but will not prevent infection from occurring. Teaching visitors not to visit when they are ill will also help prevent infection, but not to the degree that hand hygiene will.
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.
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 hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action should the nurse take?
- A. Ensure that the radiology department is aware of the isolation precautions.
- B. Plan to travel with the client to ensure appropriate precautions are used.
- C. No special precautions are needed when this client moves on unit.
- D. Notify the physician that the client cannot leave the room for the CT scan.
Correct Answer: A
Rationale: Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.