Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?
Avoiding use of a urinary catheter
Applying absorbent briefs
Restricting Fluids
Toileting patient every 4 hours
The Correct Answer is B
A. Avoiding use of a urinary catheter: While avoiding unnecessary urinary catheterization is important to prevent healthcare-associated urinary tract infections, this action may not be directly applicable to an incontinent patient who requires interventions to manage incontinence.
B. Applying absorbent briefs: Using absorbent briefs helps contain urine and feces, reducing the risk of skin breakdown and contamination of the environment.
C. Restricting Fluids: Restricting fluids may lead to dehydration and is not a recommended approach for preventing healthcare-associated infections in incontinent patients.
D. Toileting patient every 4 hours: Toileting frequency should be individualized based on the patient's needs and not restricted to a specific time interval. Additionally, simply toileting the patient may not be sufficient to prevent healthcare-associated infections if proper hygiene practices are not followed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Signs of infection: Older adults may have compromised immune systems and are more susceptible to infections. During dressing changes, the nurse should assess for signs of infection such as increased redness, swelling, warmth, drainage, or foul odor, which could indicate an infection at the wound site.
B. Skin color changes: While changes in skin color can be indicative of various skin conditions or circulation problems, assessing for signs of infection is more pertinent during dressing changes to prevent and manage complications.
C. Decreased pain levels: Older adults may have altered pain perception due to age-related changes or comorbidities. However, assessing for signs of infection takes priority during dressing changes to ensure timely intervention if infection is present.
D. Changes in blood pressure: Changes in blood pressure may be relevant in certain clinical contexts but are not specifically related to performing dressing changes in older clients.
Correct Answer is C
Explanation
A. Potassium: Potassium levels are not typically used to diagnose infection. Elevated potassium levels may indicate other health conditions such as kidney dysfunction.
B. BUN (Blood Urea Nitrogen): BUN levels assess kidney function and are not directly related to the presence of infection.
C. WBC count (White Blood Cell count): An elevation in the WBC count, specifically the neutrophil count (neutrophilia), is indicative of the body's response to infection or inflammation.
D. RBC count (Red Blood Cell count): RBC count is not typically used to diagnose infection.
Elevated RBC count may indicate conditions such as dehydration or polycythemia.
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