A nurse is teaching a newly hired group of unlicensed assistive personnel (UAP) about infectioncontrol measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?
Properly dispose of contaminated equipment
Discard used syringes into appropriate containers
Change soiled linens
Perform hand hygiene
The Correct Answer is D
Choice A reason: Properly disposing of contaminated equipment is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Contaminated equipment, such as gloves, gowns, masks, or needles, should be disposed of in designated containers or bags to prevent exposure or injury to others. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.
Choice B reason: Discarding used syringes into appropriate containers is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Used syringes, especially those that contain blood or body fluids, should be discarded into punctureresistant, leakproof, and labeled containers to prevent needlestick injuries or exposure to others. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.
Choice C reason: Changing soiled linens is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Soiled linens, especially those that contain blood or body fluids, should be changed and handled with gloves and minimal agitation to prevent contamination or aerosolization of pathogens. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.
Choice D reason: Performing hand hygiene is the most effective way to prevent the spread of pathogens during client care, because it reduces the number of microorganisms on the hands of the health care worker, which are the most common source and mode of transmission of infection. Hand hygiene should be performed before and after contact with the client, after contact with potentially infectious materials, after removing gloves, and before and after performing invasive procedures. Hand hygiene can be performed by washing with soap and water or using alcoholbased hand rubs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The client having a butterfly rash is not a concerning finding in a client with SLE. A butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of SLE and may flare up or fade depending on the disease activity. It does not indicate any serious complication or organ damage.
Choice B reason: A blood pressure of 126/85 mm Hg is not a concerning finding in a client with SLE. This blood pressure is within the normal range and does not indicate hypertension or hypotension. Hypertension is a possible complication of SLE that may affect the kidneys, the heart, or the brain. Hypotension may indicate shock, dehydration, or infection.
Choice C reason: The client reporting chronic fatigue is not a concerning finding in a client with SLE. Chronic fatigue is a common symptom of SLE that affects the quality of life and the ability to perform daily activities. It may be caused by inflammation, pain, anemia, depression, or medication side effects. It does not indicate any acute or lifethreatening condition.
Choice D reason: A urine output of 20 mL/hour is a concerning finding in a client with SLE. This urine output is below the normal range of 30 to 50 mL/hour and indicates oliguria, which is a reduced urine production. Oliguria may indicate acute kidney injury, which is a serious complication of SLE that may lead to renal failure or death. The nurse should monitor the client's urine output, fluid balance, electrolytes, and kidney function and report any abnormal findings to the provider.
Correct Answer is D
Explanation
Choice A reason: "Because it is easy to digest." is not the best response by the nurse. This is not a valid reason for giving protein supplements to a client with a bed sore. Protein supplements may or may not be easy to digest depending on the type and amount of protein and the client's digestive system. The ease of digestion is not the main goal of protein supplementation.
Choice B reason: "If you don't like it, you don't have to take it." is not the best response by the nurse. This is a dismissive and unprofessional response that does not address the client's question or concern. Protein supplements are prescribed for a reason and the client should be educated on the benefits and risks of taking or refusing them. The nurse should also respect the client's preferences and choices and offer alternatives if possible.
Choice C reason: "These supplements have nothing to do with your wound." is not the best response by the nurse. This is a false and misleading statement that contradicts the evidencebased practice of wound care. Protein supplements have a lot to do with wound healing as they provide the essential nutrients for tissue repair and regeneration. Protein deficiency can impair wound healing and increase the risk of infection and complications.
Choice D reason: "Protein has amino acids that promote wound healing." is the best response by the nurse. This is a factual and informative statement that explains the rationale for giving protein supplements to a client with a bed sore. Protein is composed of amino acids, which are the building blocks of cells and tissues. Amino acids are involved in various processes of wound healing, such as collagen synthesis, angiogenesis, and immune response. Protein supplementation can enhance wound healing and prevent protein malnutrition.
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