A nurse is selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?

A client who has ascites and had a paracentesis 4 hr ago

A client who is 6 hr postoperative following a hip arthroplasty

A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion

A client who has pneumonia and is receiving 100% oxygen via a nonrebreather mask

Answer and Explanation

The Correct Answer is A

This client has undergone a paracentesis for ascites, and since it was done 4 hours ago, they are likely stable and can be considered for discharge.

The client who is 6 hours postoperative following a hip arthroplasty may still require close monitoring and postoperative care. Discharging a postoperative client too early could lead to complications.

The client with a blood glucose level of 380 mg/dL receiving insulin via IV infusion requires ongoing monitoring and management of their diabetes. Discharging this client during an external disaster may not be appropriate due to the need for continued medical intervention.

The client with pneumonia receiving 100% oxygen via a nonrebreather mask likely requires continued medical attention and monitoring. Discharging a client with pneumonia who requires high-flow oxygen can pose risks to their respiratory status.

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Correct Answer is C

Explanation

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it: This action is appropriate as long as the specimen is labeled correctly and stored at the correct temperature. Proper handling of specimens is essential for accurate testing and does not represent an infection control hazard.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill: This action is appropriate for cleaning a contaminated surface. Chlorhexidine is an effective disinfectant for blood spills. Therefore, this action does not represent an infection control hazard.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster: While alcohol-based antiseptics are effective for most pathogens, varicella zosteris primarily spread through direct contact and airborne transmission. It is recommended to wash hands with soap and water after caring for a patient with varicella zoster, especially if hands are visibly soiled. This action may not adequately control the infection hazard.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture: This action is appropriate as long as sterile technique is maintained. Using sterile saline for irrigation is standard practice to minimize the risk of introducing pathogens before specimen collection. Therefore, this action does not represent an infection control hazard.

A. Use an air-assisted device. B. Position the bed in reverse Trendelenburg. C. Elevate the head of bed to a 45° angle. D. Lower the bed close to the ground.

Correct Answer is A

Explanation

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

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A nurse is selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

Correct Answer is C

Explanation

A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Correct Answer is A

Explanation

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