A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?
The client is in a private room.
The client has a dedicated vital signs machine.
The client has a vase of fresh flowers on the table.
There is hand sanitizer by the door.
The Correct Answer is C
Choice A reason: The client is in a private room is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should be in a private room, as it can reduce the exposure to pathogens or allergens that may cause infection or inflammation. The client with reduced immunity has a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection. The private room can also provide privacy, comfort, and security for the client.
Choice B reason: The client has a dedicated vital signs machine is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have a dedicated vital signs machine, as it can prevent the crosscontamination or transmission of pathogens or allergens that may cause infection or inflammation. The vital signs machine is a device that measures the blood pressure, pulse, temperature, and oxygen saturation of the client. The vital signs machine can be contaminated by the blood, body fluids, or secretions of the client or other clients, and can harbor bacteria, viruses, or fungi. The dedicated vital signs machine can also ensure the accuracy, consistency, and availability of the measurements for the client.
Choice C reason: The client has a vase of fresh flowers on the table is an observation that requires further action by the nurse, because it is inappropriate and undesirable. The client with reduced immunity should not have a vase of fresh flowers on the table, as it can increase the exposure to pathogens or allergens that may cause infection or inflammation. The fresh flowers are a source of mold, pollen, or insects, which can trigger allergic reactions, respiratory distress, or skin irritation. The fresh flowers can also contain bacteria, viruses, or fungi, which can infect the client through inhalation, ingestion, or contact. The vase of fresh flowers should be removed from the room and replaced with artificial flowers, pictures, or cards.
Choice D reason: There is hand sanitizer by the door is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have hand sanitizer by the door, as it can promote the hand hygiene and infection prevention of the client and others. Hand sanitizer is a product that contains alcohol or other agents that can kill or reduce the number of pathogens or allergens that may cause infection or inflammation. Hand sanitizer should be used by the client, the staff, and the visitors before and after entering or leaving the room, or after touching any objects or surfaces in the room.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An event that can cause serious injury to a client that should never happen in a hospital is not the best description of a sentinel event, because it is too vague and broad. It does not specify the degree of injury or the nature of the event. It also implies that some events that cause serious injury are acceptable in a hospital, which is not true.
Choice B reason: Specific events that enable a hospital to maximize reimbursement is not a description of a sentinel event, but rather a description of quality indicators or performance measures. These are criteria that reflect the quality of care provided by a hospital and affect its payment from payers. They are not related to sentinel events, which are adverse events that require immediate investigation and response.
Choice C reason: An unexpected event involving death or serious physical or psychological injury is the best description of a sentinel event, because it captures the essence and severity of the event. According to the Joint Commission, a sentinel event is "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" . Examples of sentinel events include wrongsite surgery, medication error, suicide, or abduction.
Choice D reason: Operating room event involving the use of unsafe equipment is not a description of a sentinel event, but rather an example of a potential sentinel event. It is not a general definition that applies to all sentinel events, but a specific scenario that may or may not result in death or serious injury. It also does not indicate the unexpectedness of the event, which is a key characteristic of a sentinel event.
Correct Answer is D
Explanation
Choice A reason: The client instills the prescribed number of eye drops into the conjunctival sac is a correct action, because it ensures that the medication reaches the eye surface and does not spill out. The conjunctival sac is the space between the eyelid and the eyeball.
Choice B reason: The client washes her hands before instilling the eye drops is a correct action, because it prevents the introduction of microorganisms or foreign substances into the eye. Hand hygiene is an essential infection control measure.
Choice C reason: The client sets the cap to the eye drop container down in a manner that does not contaminate it is a correct action, because it preserves the sterility of the eye drop solution and prevents crosscontamination. The cap should be placed on a clean surface with the inner side facing up.
Choice D reason: The client touches the administration dropper to the eye is an incorrect action, because it can cause injury, infection, or contamination of the eye drop solution. The administration dropper should be held close to the eye, but not touch it.
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