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Which intervention is most effective in preventing the spread of infection in a healthcare setting?
- A. Wearing gloves
- B. Using hand sanitizer
- C. Practicing hand hygiene
- D. Disinfecting surfaces
Correct Answer: C
Rationale: Practicing hand hygiene is the most effective measure to prevent the spread of infection in healthcare settings. While wearing gloves, using hand sanitizer, and disinfecting surfaces are important infection control measures, they are not as effective as proper hand hygiene. Hand hygiene, including handwashing with soap and water or using alcohol-based hand sanitizers, is crucial in preventing the transmission of pathogens from one person to another, making it the best choice among the options provided. Wearing gloves primarily protects the wearer and is not a substitute for hand hygiene. Using hand sanitizer is helpful but may not be as effective as proper handwashing. Disinfecting surfaces is important but does not address the direct transmission of pathogens through hand contact, which hand hygiene effectively prevents.
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The nurse is caring for a client who is NPO (nothing by mouth) due to a small bowel obstruction. Which nursing intervention is most important?
- A. Monitor bowel sounds
- B. Provide frequent oral care
- C. Encourage ambulation
- D. Measure abdominal girth
Correct Answer: B
Rationale: Providing frequent oral care is crucial when a client is NPO to ensure comfort and prevent drying of the oral mucosa. In this situation, the priority is maintaining oral hygiene to prevent complications such as oral mucosa breakdown. Monitoring bowel sounds may be important in assessing bowel activity, but it is not the priority when the client is NPO due to a small bowel obstruction. Encouraging ambulation can be beneficial for other conditions, but in this case, oral care takes precedence. Measuring abdominal girth is more relevant for assessing abdominal distention, which is not the priority when the client is NPO. Therefore, the most important nursing intervention is to provide frequent oral care.
Which client is at the highest risk for developing pressure ulcers?
- A. A 50-year-old client with a fractured femur
- B. A 30-year-old client with diabetes mellitus
- C. A 65-year-old client with limited mobility
- D. A 70-year-old client with a history of stroke
Correct Answer: C
Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.
What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag daily
- B. Irrigate the colostomy daily
- C. Avoid high-fiber foods
- D. Assess the stoma for color and swelling
Correct Answer: D
Rationale: The most crucial aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is essential to detect early signs of complications such as ischemia or infection. Changing the colostomy bag daily is important but not as critical as assessing the stoma for complications. Irrigating the colostomy daily is not a standard recommendation and should be performed based on healthcare provider's instructions. While avoiding high-fiber foods may be beneficial for some individuals with a colostomy, it is not the most important aspect of care compared to monitoring the stoma for complications.
The client with chronic kidney disease (CKD) is being educated about dietary modifications. Which dietary restriction should the nurse emphasize the most?
- A. Limit intake of high-fiber foods
- B. Restrict protein intake
- C. Avoid dairy products
- D. Increase fluid intake
Correct Answer: B
Rationale: The most crucial dietary restriction to emphasize for a client with chronic kidney disease (CKD) is to restrict protein intake. By restricting protein intake, the workload on the kidneys is reduced, which helps slow the progression of CKD. While high-fiber foods are generally beneficial, they may need to be limited in some individuals with CKD due to potassium concerns, making choice A less critical. Avoiding dairy products may be necessary in some cases to control phosphorus levels, but it is not as vital as restricting protein intake. Increasing fluid intake is essential for kidney health, but it is not the most critical dietary modification for clients with CKD.
The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?
- A. Encourage the client to ambulate
- B. Apply a heating pad
- C. Provide a carbonated beverage
- D. Teach relaxation techniques
Correct Answer: A
Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.