A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections.
Select the three clients whose findings indicate the program is effective.
Client 1
Client 5
Client 2
Client 3
Client 4
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I do not want to have any surgery for my cancer." This indicates the client's decision to refuse treatment, and the nurse should advocate by respecting and supporting the client's autonomy.
B. "I have contacted another surgeon to get a second opinion." Seeking a second opinion demonstrates proactive decision-making and does not require advocacy.
C. "I will discuss treatment options next week after thinking about this." The client is demonstrating autonomy by requesting time to consider options.
D. "I will take chemotherapy since my family wants me to." This indicates external pressure rather than autonomous decision-making, necessitating the nurse's role as an advocate.
Correct Answer is D
Explanation
A. Perform CPR for a client who is not breathing: CPR is within the scope of trained assistive personnel, but a nurse or advanced provider typically manages it in an emergency scenario.
B. Complete distal capillary refill checks for a client who has an open leg wound: Capillary refill checks require clinical assessment skills, which are outside the AP's scope of practice.
C. Determine which clients need priority medical treatment: Triage and prioritization require clinical judgment, which is the nurse's responsibility.
D. Answer questions from area residents who have health concerns: APs can answer non-clinical questions and provide basic information to area residents.
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