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 D

Explanation

The correct answer is: d. Remove the staple from the skin after both sides are visible.

Explanation: This statement is correct because the staple should be removed only when both sides are visible, ensuring that it has been fully lifted away from the skin. This helps minimize tissue damage and pain while preventing infection.

Choice A Rationale: Lifting the staple remover when squeezing the handle could potentially disrupt the proper angle required for effective staple removal. Staples are designed to be removed in a specific manner to minimize tissue trauma and discomfort to the patient. If the staple remover is lifted while squeezing the handle, it may cause uneven pressure on the staple legs, leading to improper removal. This could result in tissue damage, increased pain for the patient, and potentially leave parts of the staple embedded in the skin, increasing the risk of infection or delayed healing.

Choice B Rationale: Avoiding completely closing the handle after squeezing may not provide sufficient force to properly remove the staple from the skin. Staples are designed to be squeezed closed completely to ensure that they are securely grasped and removed from the incision site. Failing to fully close the handle after squeezing may result in inadequate removal of the staple, leaving parts of it behind in the skin. This can increase the risk of infection, tissue irritation, and delayed wound healing. Additionally, incomplete closure of the handle may lead to discomfort for the patient as the staple removal process may be prolonged or require additional attempts.

Choice C Rationale: Expecting the staples to bend at each outer side during removal is incorrect. Staples are designed to bend in the middle when properly removed from the skin. If the outer sides of the staple were expected to bend, it may indicate improper technique or the use of a faulty staple remover. Staples are intended to be removed smoothly without excessive bending or twisting to minimize trauma to the surrounding tissue and reduce the risk of complications such as infection or delayed wound healing. Anticipating bending at the outer sides could lead to unnecessary manipulation of the staple and increase the likelihood of tissue damage or incomplete removal.

Choice D (Correct Answer) Rationale: Removing the staple from the skin only after both sides are visible is the appropriate technique to ensure proper removal without causing unnecessary trauma or discomfort to the patient. When both sides of the staple are visible, it indicates that the staple has been adequately lifted away from the skin, reducing the risk of tissue damage or incomplete removal. This technique allows for a smooth and controlled extraction of the staple, minimizing pain and promoting optimal wound healing. By waiting until both sides are visible, the nurse can confirm that the staple has been fully disengaged from the tissue, reducing the likelihood of complications such as infection or skin irritation.

A. Offer the client a straw to drink liquids. B. Place food toward the back of the client's mouth. C. Encourage the client to lie down and rest for 30 minutes after meals. D. Instruct the client to tilt their head forward while eating.

Correct Answer is D

Explanation

The correct answer is choice D: "Instruct the client to tilt their head forward while eating."

Choice A rationale:

Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.

Choice B rationale:

Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.

Choice C rationale:

Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.

Choice D rationale:

Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.

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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

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

Correct Answer is D

Explanation

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?