Nokea
Asepsis is defined as ________________.
- A. the absence of all microorganisms
- B. the absence of disease-causing germs
- C. a urinary infection
- D. a pathogenic infection
Correct Answer: B
Rationale: Asepsis is defined as the absence of disease-causing germs. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease-causing germ, and a urinary infection is only one type of infection.
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Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.
- A. bedside rails up at all times
- B. bed in the low position
- C. call bell within reach
- D. family members in the room at all times
Correct Answer: C
Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.
Your patient has been diagnosed with herpes simplex virus 2. Which of the following would NOT be included in your teaching of this patient?
- A. If you have symptoms, you should avoid sexual contact with other individuals.
- B. With treatment, this condition can be cured.
- C. This disease is highly contagious.
- D. You may experience tingling in the skin before an active outbreak occurs.
Correct Answer: B
Rationale: The correct answer is 'With treatment, this condition can be cured.' The treatment for herpes simplex virus (HSV) is symptomatic and palliative, aimed at managing symptoms rather than curing the infection. HSV is highly contagious, so sexual contact should be avoided during active outbreaks to prevent transmission. Many patients experience a tingling sensation in the skin before an active outbreak, known as a prodrome. Educating the patient that the condition is not curable but manageable with treatment is vital to set realistic expectations and promote proper management of the disease.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?
- A. Start the hepatitis B immunization series.
- B. Teach the patient about hepatitis A immune globulin.
- C. Ask whether the patient has been screened for hepatitis C.
- D. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
Correct Answer: C
Rationale: The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.
As a nurse, you have been assigned to take over as charge nurse without any report after the previous charge nurse fell during her shift and was taken to the emergency room. At the end of the shift, you have made the assignments for the next shift's nurses and posted them. As the nurses come in, they begin to complain that the assignments make no sense based on patient acuity. One refuses to take her assignment and threatens to go home. What could you have done to prevent their dissatisfaction?
- A. Reviewed the notes of the previous charge nurse
- B. Tried to contact the previous charge nurse in the emergency room
- C. Collaborated with the nurse manager
- D. Collaborated with the other nurses on your shift
Correct Answer: D
Rationale: Collaborating with the other nurses on your shift would have permitted them to provide the most updated information regarding patient status and acuity. Requesting their input into creating assignments would have provided shared governance and assurance that the unit staffing was arranged appropriately. Reviewing the notes of the previous charge nurse might not capture the real-time changes in patient conditions. Trying to contact the previous charge nurse in the emergency room may not be feasible or timely. Collaborating with the nurse manager could be helpful, but involving the nurses directly impacted by the assignments would have been more effective in addressing their concerns and ensuring appropriate patient care.
Which risk factor places patients and residents at the greatest risk for falls?
- A. Old age
- B. Middle age
- C. Pneumonia
- D. COPD
Correct Answer: A
Rationale: Old age is a significant risk factor for falls as elderly individuals are more prone to falls due to factors like decreased balance, muscle strength, and vision. Middle age is less associated with falls compared to old age. Pneumonia and COPD are medical conditions that are not direct risk factors for falls, unlike aging which significantly increases the risk of falls.