Nokea
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.
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The nurse is assisting a client in selecting appropriate food options for dumping syndrome. Which foods would be suitable choices? Select all that apply.
- A. Rice cereal
- B. Pastries
- C. Chicken breast
- D. Cola
- E. Scrambled eggs
Correct Answer: A,C,E
Rationale: Rice cereal, chicken breast, and scrambled eggs are low-sugar, high-protein options suitable for dumping syndrome. Pastries and cola are high-sugar, triggering symptoms.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 5 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
Which of the following instructions should the nurse include when teaching the client how to ambulate with a walker? Select all that apply.
- A. The top of the walker should line up with your wrist crease.
- B. Lean over the walker to maintain good balance.
- C. When going up the stairs, advance the walker up onto the step first.
- D. When getting up from a chair, use the chair's armrests to push yourself up.
- E. Move the walker forward 2 to 4 inches with each step.
Correct Answer: A,D
Rationale: The walker should align with the wrist crease for proper height, and using chair armrests ensures safe standing. Leaning over the walker risks imbalance, and the walker follows the stronger leg on stairs.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The nurse is visiting an older adult client with impaired vision. It would be necessary for the nurse to follow up if the client states which of the following? Select all that apply.
- A. I secured my throw rugs to the floor with tape.
- B. I switched to using an electric shaver instead of a razor.
- C. I usually sit in a recliner while I listen to the television.
- D. I use different shaped containers with lids to organize my medications.
- E. I use the upstairs bathroom instead of the one on the main floor.
Correct Answer: E
Rationale: Using an upstairs bathroom increases fall risk for a visually impaired client, requiring follow-up. Securing rugs, using an electric shaver, sitting in a recliner, and organizing medications are safe practices.
The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling?
- A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia
- B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide
- C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone
- D. 28-year-old admitted with bacteremia is receiving intravenous fluids via central line and is diaphoretic
Correct Answer: A
Rationale: The 88-year-old with dementia is at highest fall risk due to age and cognitive impairment.