Question

Integral components of client care

1. A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease?

1. Have the client wear a mask when coming from admission
2. Stock the supply cart at the beginning of each shift
3. Wash the hands only after leaving the room
4. Wear a mask when exiting the room

2. A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Select all that apply

1. Thorough hand hygiene
2. The importance of adequate nutrition
3. Covering the mouth and nose when coughing or sneezing
4. Increasing contact with others
5. Restricting rest period

3. What items should the nurse ensure are included in the room of a client who is in contact isolation?

6. Cabinet stocked with gowns and gloves
7. Cards and records
8. Paper towels, sink, blood pressure cuff
9. Sign on the door

4. When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?

1. Goggles
2. Gown
3. Surgical mask
4. Clean gloves

5. While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to take?

1. Remove the glove and start over with a new pair.
2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand.
3. Ask a colleague to assist by unrolling the cuff.
4. Leave the cuff rolled under.

6. The nurse evaluates the chart of a 65-year-old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply.

1. Last tetanus booster was at age 50
2. Receives a flu shot every year
3. Has not received the hepatitis B vaccine
4. Has not received the hepatitis A vaccine
5. Has not received the herpes zoster vaccine

7. A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _____________.

8. After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred?

1. “We will use antimicrobial soap and hot water to wash our hands at least three times per day.”
2. “We must wash or peel all raw fruits and vegetables before eating.”
3. “A wound or sore is not infected unless we see it draining pus.”
4. “We should not share toothbrushes but it is OK to share towels and washcloths.”

10.   The nurse determines that a field remains sterile if which of the following conditions exist?

1. Tips of wet forceps are held upward when held in ungloved hands.
2. The field was set up 1 hour before the procedure.
3. Sterile items are 2 inches from the edge of the field.
4. The nurse reaches over the field rather than around the edges.

Answer 1

ANSWER 1:

• a.) HAVE THE CLIENT WEAR A MASK WHEN COMING FROM ADMISSION.

REASON:

• ESSENTIAL NURSING ACTION TO PREVENT TRANSMISSION OF INFECTION IN THE CARE AREA.

ANSWER 2:

• a.) THOROUGH HAND HYGIENE.
• b.) THE IMPORTANCE OF ADEQUATE NUTRITION.

REASON:

• PERSONAL HYGIENE TO AVOID INFECTION.
• HEALTHY DIET TO IMPROVE THE NUTRITIONAL STATUS .
• LIMITATION OF MOVEMENT TO AVOID INCISION SPLIT .
• REST PERIOD SHOULD BE ADEQUATE.AVOID CONTACT WITH OTHERS TO PREVENT INFECTION.

ANSWER 3:

• a.) CABINET STOCKED WITH GOWNS AND GLOVES.
• c.) PAPER TOWELS, SINK, BLOOD PRESSURE CUFFS.
• d.) SIGN ON THE DOOR.

REASONS:

• THE ISOLATION ROOM MUST HAVE ALL THE THINGS REQUIRED FOR INFECTION PREVENTION.

ANSWER 4:

• a.) GOGGLES

REASON:

• GOWN, SURGICAL MASK AND GLOVES SHOULD BE DISCARDED AFTER EACH USE.

ANSWER 5:

• b.) WAIT UNTIL THE SECOND GLOVE IS IN PLACE AND THEN UNROLL THE CUFF WITH THE OTHER STERILE HAND.

ANSWER 6:

• a.) LAST TETANUS BOOSTER WAS AT AGE 50.
• d.) HAS NOT RECEIVED THE HERPES ZOSTER VACCINE.

REASON:

• TDAP BOOSTER EVRY 10 YEARS
• EFFECTS AND COMPLICATIONS OF HERPES ZOSTER INCREASES OVER YEARS.

ANSWER 7:

• IMPAIRED TISSUE INTEGRITY .

REASON:

• INADEQUATE NUTRITION RESULTS IN SKIN BREAKDOWN

ANSWER 8:

• a.)" WE WILL USE ANTIMICROBIAL SOAP AND HOT WATER TO WASH OUR HANDS AT LEAST THREE TIMES PER DAY."

REASON: PERSONAL HYGIENE IS ESSENTIAL TO AVOID INFECTION.

ANSWER 10:

• c.) STERILE ITEMS ARE 2 INCHES FROM THE EDGE OF THE FIELD.
• d.)THE NURSE REACHES OVER THE FIELD RATHER THAN AROUND THE EDGES.