A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections.

Exhibits

Select the three clients whose findings indicate the program is effective.

Client 1

Client 5

Client 2

Client 3

Client 4

Answer and Explanation

Correct Answer : B,C,D

A.   Client 1: Worsening of the pressure injury with purulent drainage indicates infection and failure of pressure injury prevention strategies.
B.   Client 5: The stage 3 pressure injury reduced in size and severity to stage 2, with the absence of purulent drainage, indicating wound healing and effective intervention.
C.   Client 2: WBC count decreased from 11,500/mm³ to within the normal range at 9,500/mm³, indicating improvement in pneumonia.
D.   Client 3: Temperature reduced from 38.9°C to 38°C, with stabilization of vital signs, suggesting improvement in the wound infection.
E.   Client 4: An increase in WBCs in the urine from 2 to 6 per low-power field suggests worsening of the urinary tract infection, indicating program ineffectiveness.

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Correct Answer is D

Explanation

A. "Have you tried holding your infant skin-to-skin?": Important for bonding and soothing but not the priority for postoperative care.
B. "Have you considered joining a parents' support group?": Beneficial for emotional support but not immediately essential for the infant's recovery.
C. "What is your infant's level of activity?": Relevant for assessing overall recovery but not the most critical issue.
D. "Is your infant able to latch on during breastfeeding?" Feeding is the priority concern after cleft palate repair to ensure adequate nutrition and assess for complications.

A. Inform the charge nurse. B. Send the client for the test with the unsigned form. C. Obtain consent from a family member. D. Wake the client and ask them to sign the form.

Correct Answer is A

Explanation

A. Inform the charge nurse. The charge nurse should be notified when consent cannot be obtained so appropriate steps can be taken, such as rescheduling or involving the healthcare provider.
B. Send the client for the test with the unsigned form. Consent must be obtained before any invasive procedure. Proceeding without consent can result in legal and ethical consequences.
C. Obtain consent from a family member. A family member cannot give consent unless they hold legal power of attorney for healthcare decisions.
D. Wake the client and ask them to sign the form. Consent obtained under the influence of sedatives is not legally valid as it compromises the client's decision-making capacity.

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A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections. Exhibits Select the three clients whose findings indicate the program is effective.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

A nurse is caring for a client who has refused medications. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is discussing conflict resolution with a group of assistive personnel. Which of the following information should the nurse include in the discussion?

A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

A nurse receives care assignments for a group of clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? (Select all that apply.)

A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

A nurse is reinforcing teaching about ethical dilemmas with a newly licensed nurse. Which of the following should the nurse identify as the first step in the ethical reasoning process?

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections.

Exhibits

Select the three clients whose findings indicate the program is effective.