A nurse is teaching a newly licensed nurse about reducing the risk for healthcare-associated infections.
Which of the following instructions should the nurse include?
Use chlorhexidine gluconate to clean skin on clients who are preoperative.
Irrigate indwelling urinary catheters daily.
Change a gauze dressing over central vascular access devices every 3 days.
Provide mouth care every 8 hrs for clients who require mechanical ventilation.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"Role performance overload" is not a direct adverse effect of a negative body image. Role performance overload refers to excessive demands and responsibilities in one's life, which can lead to stress and burnout. While a negative body image can contribute to stress, it does not directly cause role performance overload.
Choice B rationale:
"Development of an eating disorder" is a well-documented adverse effect of a negative body image. Individuals with a negative body image may develop eating disorders like anorexia nervosa or bulimia as they strive for an idealized body image. This choice is directly related to the topic of negative body image.
Choice C rationale:
"Mistrust" is not a typical adverse effect of a negative body image. Mistrust is more related to issues of trust and interpersonal relationships, while a negative body image primarily affects one's self-perception.
Choice D rationale:
"Self-absorption" can be a consequence of a negative body image, as individuals may become preoccupied with their appearance and self-worth based on their body. However, the most direct and severe consequence is the development of eating disorders, as mentioned in choice B. .
Correct Answer is A
Explanation
Choice A rationale:
When caring for a client at the end of life who is unresponsive, it is essential to maintain a compassionate and supportive presence. Continuing to talk to the client as if they are awake is a respectful and therapeutic approach. Even though the client may not respond verbally, they may still be able to hear and sense the presence of their loved ones and the healthcare team. This communication can provide comfort and reassurance.
Choice B rationale:
Limiting the client's visitors to one at a time is a reasonable consideration, as it can help reduce potential overwhelm and maintain a calm environment. However, this choice should be based on the client's and family's preferences. Some clients and families may prefer to have multiple visitors present for support and companionship during this difficult time.
Choice C rationale:
Avoiding touching the client is not recommended when caring for an unresponsive client at the end of life. Physical touch, when gentle and respectful, can convey comfort and support. The nurse should be sensitive to the client's preferences and the family's wishes regarding physical contact.
Choice D rationale:
Whispering when talking in the client's room is not necessary. While it's important to maintain a quiet and peaceful environment, speaking in a normal tone is appropriate. The client may still be able to hear and may find comfort in the familiar voices of their loved ones and the healthcare team. .
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