Nokea
The nurse is discussing infection control with a group of nursing students. Which indication would be appropriate for the nurse to use an alcohol-based sanitizer? Select all that apply.
- A. Immediately before touching a client
- B. After applying sterile gloves
- C. When changing linens for a client infected with Clostridium difficile
- D. After changing a diaper for an infant infected with norovirus
- E. After collecting vital signs on a client with human immunodeficiency virus (HIV)
Correct Answer: A,E
Rationale: Alcohol-based sanitizers are effective before touching a client and after non-soiled contact like vital signs for HIV. They are ineffective for C. difficile or norovirus, and hand washing is needed after applying gloves.
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The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication?
- A. Passive range of motion
- B. Sequential compression devices (SCDs)
- C. Early ambulation
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Early ambulation promotes lung expansion and secretion clearance, reducing pneumonia risk. Other options are less effective for this purpose.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
The nurse is preparing to remove an intrajugular central venous catheter. It would be appropriate to place the client in which position for this procedure?
- A. Reverse Trendelenburg
- B. Left lateral
- C. Trendelenburg
- D. High-Fowler's
Correct Answer: C
Rationale: Trendelenburg position (head down) reduces the risk of air embolism during intrajugular catheter removal by increasing venous pressure. Other positions do not minimize this risk effectively.
The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.
- A. A client who had rectal surgery and a post-operative abscess
- B. A child who has pneumonia
- C. An older client who is post-myocardial infarction (MI)
- D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia
- E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)
Correct Answer: A,D,E
Rationale: Rectal temperature is contraindicated in rectal surgery/abscess (due to trauma risk), neutropenia (infection risk), and DIC (bleeding risk). Pneumonia and post-MI do not contraindicate rectal measurement.
The nurse is performing hand hygiene. Which actions should the nurse take when washing their hands with soap and water? Select all that apply.
- A. Use a paper towel to turn off the faucet.
- B. Keep the hands and forearms lower than the elbows during washing.
- C. Wash hands using hot water.
- D. Rinse the hands and wrists by keeping the hands down and elbows up.
- E. Wash hands for 5 to 10 seconds.
Correct Answer: A,B,D
Rationale: Using a paper towel, keeping hands lower, and rinsing correctly prevent contamination. Hot water is harsh, and washing should last 40-60 seconds.