A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Place immunocompromised clients in the same room.

Wash hands after removing gloves.

Use antimicrobial hand gel after refilling a client's water pitcher.

Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

Answer and Explanation

Correct Answer : B,C,D

The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

Choice A rationale:

Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.

Choice B rationale:

Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.

Choice C rationale:

Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.

Choice D rationale:

Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.

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Correct Answer is C

Explanation

The correct answer is choice C. Pallor with scaly skin.

Choice A rationale:

"Heart rate 89/min." Heart rate within the range of 60-100 beats per minute is generally considered normal for adults at rest. This value doesn't specifically indicate malnourishment.

Choice B rationale:

"Pink mucous membranes." Pink mucous membranes indicate adequate oxygenation and hydration but don't necessarily reflect nutritional status or malnourishment.

Choice C rationale:

"Pallor with scaly skin." Pallor (pale skin) along with scaly skin can be indicative of malnourishment. Malnourished individuals may not receive adequate n

Choice D rationale:

"Body mass index 23." A body mass index (BMI) of 23 falls within the normal range (18.5-24.9), so it doesn't necessarily indicate malnourishment. However, BMI alone may not fully capture malnourishment, as it doesn't consider other factors like muscle mass and specific nutrient deficiencies.

A. A client who plans to leave the facility against medical advice. B. A client who informs the nurse that they have made their funeral arrangements. C. A client who tells the nurse that the night shift nurse did not bring their medication. D. A client who has just experienced the death of their child.

Correct Answer is D

Explanation

The correct answer is choice D: A client who has just experienced the death of their child.

Choice A rationale:

Offering silence to a client who plans to leave the facility against medical advice might not be the most appropriate therapeutic communication technique. Silence in this situation could be misconstrued as ignoring the client's concerns or not addressing their reasons for wanting to leave. Active listening and open-ended questioning would likely be more effective in understanding and addressing the client's concerns.

Choice B rationale:

A client who informs the nurse that they have made their funeral arrangements is expressing thoughts and emotions that might require sensitive communication. Silence in this context could be interpreted as neglecting the client's need for support and empathy. The nurse should engage in a compassionate conversation and encourage the client to share their feelings.

Choice C rationale:

For a client who tells the nurse that the night shift nurse did not bring their medication, silence would not be the most suitable response. This situation calls for clarification and action, as the nurse needs to address the medication discrepancy promptly. Engaging in open communication and resolving the issue is essential here.

Choice D rationale:

A client who has just experienced the death of their child is likely overwhelmed with grief and intense emotions. In this scenario, using the therapeutic communication technique of silence can provide the client with a supportive space to process their feelings. Offering a moment of silence acknowledges the depth of their emotions and gives them the opportunity to express themselves when they are ready.

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A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Nursing Test Bank

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Correct Answer is C

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Correct Answer is D

Explanation

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