Nokea
The nurse is caring for a patient withClostridiumdifficile. Which nursing actions will have thegreatest impact in preventing the spread of the bacteria?
- A. Appropriate disposal of contaminated items in biohazard bags
- B. Monthly in-services about contact precautions
- C. Mandatory cultures on all patients
- D. Proper hand hygiene techniques
Correct Answer: D
Rationale: Correct Answer: D - Proper hand hygiene techniques
Rationale:
1. Clostridium difficile is mainly spread through contact with contaminated surfaces.
2. Proper hand hygiene is the most effective way to prevent the spread of bacteria.
3. Hand hygiene removes bacteria from hands, reducing the risk of transmission.
4. Appropriate disposal (A) is important but doesn't directly prevent spread. Monthly in-services (B) and mandatory cultures (C) are not as effective as hand hygiene in preventing transmission.
You may also like to solve these questions
The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patients health education?
- A. The need to limit exposure to bright light
- B. The need to maintain a low Fowlers position when removing the prosthesis
- C. The need to perform thorough hand hygiene before handling the prosthesis
- D. The need to apply antiviral ointment to the prosthesis daily
Correct Answer: C
Rationale: The correct answer is C: The need to perform thorough hand hygiene before handling the prosthesis. This is crucial to prevent infection. By washing hands thoroughly, the patient reduces the risk of introducing harmful bacteria or pathogens to the prosthesis, which could lead to infections or other complications.
Incorrect Choices:
A: The need to limit exposure to bright light - This is not directly related to caring for an ocular prosthesis.
B: The need to maintain a low Fowlers position when removing the prosthesis - Positioning is not typically a concern when caring for an ocular prosthesis.
D: The need to apply antiviral ointment to the prosthesis daily - Antiviral ointment is not a standard part of ocular prosthesis care unless specifically prescribed by a healthcare provider for a particular reason.
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
- A. Evaluate the patients milk production.
- B. Palpate the area for a breast mass.
- C. Assess the patients knowledge of breast cancer.
- D. Assure the patient that this likely an age-related change.
Correct Answer: B
Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation.
Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling.
Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling.
Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.
A patients ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patients discharge education?
- A. Disturbed body image
- B. Chronic pain
- C. Ineffective protection
- D. Unilateral neglect
Correct Answer: A
Rationale: The correct answer is A: Disturbed body image. Enucleation can have a significant impact on a patient's self-image and self-esteem. By addressing this nursing diagnosis, the nurse can help the patient cope with the changes in their physical appearance and support them in adjusting to wearing a prosthesis.
Summary:
- Choice B (Chronic pain) is incorrect because enucleation may cause acute pain initially, but chronic pain is not a common concern post-enucleation.
- Choice C (Ineffective protection) is incorrect because enucleation does not necessarily affect the eye's protection mechanism.
- Choice D (Unilateral neglect) is incorrect as it refers to a neurological condition unrelated to the patient's situation post-enucleation.
A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply.
- A. Pain control
- B. Management of treatment complications
- C. Interpretation of diagnostic tests
- D. Assistance with self-care E) Administration of treatments
Correct Answer: A
Rationale: The correct answer is A: Pain control. This is the main focus because the patient's quality of life should be prioritized, and managing pain is crucial for comfort and well-being in end-of-life care. Pain can significantly impact the patient's physical and emotional state. The other choices are incorrect because managing treatment complications (B) and administering treatments (E) may not be relevant if the tumor is inoperable and the patient has a short life expectancy. Interpretation of diagnostic tests (C) may not be necessary at this stage, and assistance with self-care (D) may not be the main priority compared to pain control.
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
- A. Perianal region and oral mucosa
- B. Sacral region and lower abdomen
- C. Scalp and skin over the scapulae
- D. Axillae and upper thorax
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions.
Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients.
Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS.
Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.