Nokea
The nurse has attended a staff education program about indwelling urinary catheter-associated infections (CAUTI). Which nursing intervention is most effective in preventing a CAUTI in hospitalized clients?
- A. Implementing strict sterile technique during catheter insertion and maintenance.
- B. Using antibacterial indwelling urinary catheters for all clients requiring urinary catheterization.
- C. Limiting the duration of indwelling urinary catheter use and promptly removing them when no longer needed
- D. Administering prophylactic antibiotics to all clients with indwelling urinary catheters in place.
Correct Answer: C
Rationale: Limiting catheter duration is the most effective way to prevent CAUTI, as prolonged use increases infection risk.
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A nurse is caring for a client who is admitted to the hospital with suspected osteomyelitis. Which of the following laboratory tests should the nurse anticipate being ordered to aid in the diagnosis and monitoring of this condition?
- A. Erythrocyte sedimentation rate (ESR)
- B. Serum potassium levels
- C. Serum creatinine levels
- D. Prothrombin time (PT)
Correct Answer: A
Rationale: ESR is a marker of inflammation, commonly elevated in osteomyelitis, aiding in diagnosis and monitoring.
The nurse is assessing her prenatal client for sexually transmitted infections (STIs) by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply.
- A. Low socioeconomic status
- B. A monogamous relationship
- C. A past history of working in the sex industry
- D. Illicit drug use
- E. History of cancer
- F. Previous history of STIs
Correct Answer: A,C,D,F
Rationale: Low socioeconomic status, sex work, illicit drug use, and previous STIs increase STI risk due to behavioral and social factors.
The following scenario applies to the next 1 items
The nurse in the urgent care clinic is caring for a 22-year-old male client.
Item 1 of 1
Nurses' Notes
Orders
Procedure Note
1400: Client reports swelling, erythema, and painful lesion to the left upper extremity. The client reports that he noticed a pimple-like lesion three days ago that grew in size and became painful over the course of three days. The client has a medical history of diabetes mellitus (type one) and has noticed higher-than-normal blood glucose levels. The client reports that pain has increased to a level where he cannot go to the gym daily. On assessment, the client has a large, reddened pustule in the left upper extremity. Pain rated 7/10 on the Numerical Rating Scale. Vital signs: T 98.7° F (37.1° C) P 88 RR 16 BP 138/84 Pulse oximetry reading 99% on room air.
1519: Bedside I&D performed by physician. Applied 4x4 gauze sponge to the wound and wrapped with rolled sterile gauze. Culture and sensitivity were obtained and sent to the lab.
1610: Discharged client home. Discharge teaching provided. Vital signs: T 98.7° F (37.1° C) P 82 RR 17 BP 133/81 Pulse oximetry reading 98% on room air.
The nurse provides the client with discharge teaching on wound care and the prescribed antibiotic.
The nurse provides the client with discharge teaching on wound care and the prescribed antibiotic. For each of the statements made by the client, click to specify whether the statement indicates an understanding or no understanding of the discharge teaching provided.
- A. I should increase my overall fluid intake to 3 liters daily.
- B. I should wear a broad-spectrum sunscreen while outdoors.
- C. This infection may raise my glucose level.
- D. I may have to change antibiotics depending on the lab test results.
- E. I should keep the wound open to air while sleeping.
- F. I will place soiled bandages in a plastic bag and seal it closed before placing it in the regular trash.
- G. I should wash the infected area before washing the uninfected areas with a washcloth.
Correct Answer: A: Understanding, B: No Understanding, C: Understanding, D: Understanding, E: No Understanding, F: Understanding, G: Understanding
Rationale: A: Adequate fluid intake supports healing and antibiotic efficacy. B: Sunscreen is unrelated to wound care. C: Infections can elevate glucose levels, especially in diabetics. D: Antibiotic adjustments may be needed based on culture results. E: Wounds should be kept covered to prevent contamination. F: Proper disposal of bandages prevents infection spread. G: Washing the infected area first prevents spreading bacteria.
The nurse is assessing a client with suspected Lyme disease. Which of the following findings would support a diagnosis of Lyme disease? Select all that apply.
- A. lymphadenopathy
- B. fatigue
- C. petechial rash
- D. arthralgias
- E. hemoptysis
Correct Answer: B,D
Rationale: Fatigue and arthralgias are common symptoms of Lyme disease, supporting the diagnosis.
The emergency department nurse is caring for a client exposed to inhalation anthrax. It would be essential for the nurse to take which action?
- A. Initiate continuous pulse oximetry
- B. Obtain a prescription for a chest radiograph
- C. Notify the public health department
- D. Prepare the client for a lumbar puncture
Correct Answer: C
Rationale: Inhalation anthrax is a reportable disease, and notifying the public health department is essential for containment and surveillance.