Nokea
Which of the following actions is most effective at reducing the incidence of health-care-associated infections?
- A. Screen all newly admitted clients for colonization or infection with MRSA.
- B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms.
- C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.
- D. Require nursing staff to wear gowns to change wound dressings for all clients.
Correct Answer: C
Rationale: Alcohol-based hand rub availability is the most effective way to reduce healthcare-associated infections by promoting frequent hand hygiene. MRSA screening, automatic antibiotics, and universal gown use are less effective or inappropriate.
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The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?
- A. Bring a penlight from the side of the client's face and briefly shine the light on the pupil.
- B. Ask the client to gaze at a distant object and then at a test object close to them.
- C. Obtain a tuning fork and place it in the middle of the client's forehead.
- D. Have the client stand twenty feet away from a Snellen chart.
Correct Answer: B
Rationale: Accommodation is tested by having the client shift gaze from a distant to a near object, observing pupil constriction and convergence. Penlight tests pupil response, tuning fork tests hearing, and Snellen tests vision.
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client
- A. withdrawing from alcohol and is malnourished.
- B. receiving methylprednisolone for an asthma exacerbation.
- C. has an external urinary catheter device for urinary incontinence.
- D. receiving total parenteral nutrition (TPN) via a central line
Correct Answer: D
Rationale: TPN via a central line poses the highest infection risk due to the invasive device and nutrient-rich solution.
The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.
- A. The client reports feeling nauseated.
- B. The client's lower extremities are swollen.
- C. The client expresses nervousness about test results.
- D. The client reports that their leg is itching.
- E. The client rates pain at a 6 on a scale of 1 to 10.
- F. The client vomits twice after eating dinner.
Correct Answer: A,C,D,E
Rationale: Subjective data are client-reported, like nausea, nervousness, itching, and pain rating. Swelling and vomiting are objective, observed by the nurse.
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 2 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
The nurse reviews the assessment data and analyzes the individual's risk for falling. Click to specify whether each assessment finding is a risk factor for falling or not.
- A. Ambulation pattern
- B. Speech pattern
- C. Age
- D. Gender
- E. Fall history
- F. Current medications
Correct Answer: A,C,E,F
Rationale: Ambulation pattern, age (older adults), fall history, and medications (e.g., diazepam) are fall risk factors. Speech pattern and gender are not direct risk factors.
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply.
- A. Place a small pillow between the client's knees.
- B. Places the client's arms at their side.
- C. Fanfold a drawsheet along the backside of the client.
- D. Instruct the client to laterally flex the neck during the turn.
- E. Roll the client as one unit in a smooth, continuous motion.
Correct Answer: A,B,C,E
Rationale: Pillow placement, arms at sides, drawsheet use, and rolling as a unit maintain spinal alignment. Neck flexion risks injury during log rolling.