A. This response acknowledges the parent's concern but maintains confidentiality regarding the report. It offers to involve the supervisor, which is a reasonable step. However, it may leave the parent feeling uneasy or uncertain.
B. This response directly informs the parent about the legal obligation of the nurse to report suspected child abuse. It provides clarity on why the nurse took action. However, it might be perceived as abrupt or lacking empathy.
C. This response suggests that someone else (possibly a healthcare provider or another authority figure) will explain the situation later. It doesn't directly address the reason for the nurse's action or the legal requirement to report.
D. This response explains the chain of events, from reporting to the supervisor's decision to contact authorities. It provides information but might not directly address the parent's emotional concern or the legal obligation of the nurse.

A. Calling the healthcare provider is a reasonable action, especially when there is a significant change in the patient's condition, such as weight gain and generalized edema. The nurse may need further guidance on adjusting medications or additional interventions.

B. Diuretics are commonly prescribed for patients with heart failure to manage fluid overload. If the patient has not been compliant with taking their diuretic as prescribed, it could contribute to fluid retention and exacerbation of symptoms. Therefore, ensuring medication adherence is important. However, this alone may not address the acute issue of current weight gain and edema.
C. Daily weight monitoring is crucial for patients with heart failure as it can indicate fluid retention early on. Reinforcing the importance of daily weights helps in early detection of changes and facilitates timely intervention. However, in this scenario, the nurse has already noted a significant weight gain and edema since the last visit, so immediate action beyond education is needed.
D. Documenting the findings is essential for maintaining accurate patient records. However, in the context of a patient with heart failure who has shown signs of worsening (weight gain and edema), immediate action to address the worsening condition is necessary.

A. Pain management is important during labor, but in this scenario, the priority is not pain relief but rather addressing potential complications or needs related to the vital signs and labor progress.
B. This position can help improve blood flow to the uterus and placenta, which is crucial given the low maternal blood pressure (92/54 mm Hg). This action can help stabilize the client's condition while further assessments and interventions are planned.
C. Emptying the bladder is often recommended during labor to ensure there is no obstruction to the progress of labor and to reduce the risk of urinary retention. While important, it is not the priority action based on the information provided.
D. The nurse also needs to report the contraction pattern (duration of 1 min, frequency of 3 min) and fetal heart rate (130/min) to ensure appropriate monitoring and management by the healthcare provider. However, this should not delay lifesaving interventions such as positioning.

A. An inguinal hernia typically does not directly contribute to an increased risk of falls. It is a condition where tissues, such as part of the intestine, protrude through a weak spot in the abdominal muscles. While it may require caution with certain movements or heavy lifting to prevent exacerbation, it is not typically associated with balance or mobility issues that would increase fall risk.
B. Hyperthyroidism is a condition where the thyroid gland produces excessive thyroid hormone. Symptoms may include nervousness, tremors, rapid heart rate (palpitations), and muscle weakness. While muscle weakness could potentially contribute to an increased fall risk, it's not typically a primary factor unless the weakness is severe or affecting lower extremity strength significantly.
C. Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, such as cholesterol and triglycerides. While it is a risk factor for cardiovascular disease, it does not directly increase the risk of falls.
D. Multiple sclerosis (MS) is a neurological condition that can cause a wide range of symptoms, including muscle weakness, coordination problems, and balance issues. These neurological impairments significantly increase the risk of falls due to impaired mobility and balance control.

A. Proper oral hygiene is crucial for preventing ventilator-associated pneumonia (VAP), which is a common complication in ventilated patients. The bundle often includes instructions on how to perform mouth care to reduce the risk of bacterial colonization in the oral cavity and subsequent aspiration into the lungs.
B. Tracheostomy care, including suctioning as needed, is important to maintain airway patency and prevent complications like mucus plugging. However, specific instructions for suctioning frequency (e.g., every 2 hours) may vary based on the patient's clinical condition and the presence of secretions. It is not universally part of the ventilator care bundle but is an essential component of managing patients with tracheostomies.
C. Correct ventilator settings are critical to support adequate oxygenation and ventilation while minimizing lung injury. Nurses should be knowledgeable about how to monitor and adjust ventilator settings based on the patient's respiratory status. Education on ventilator settings may be included in

training related to mechanical ventilation management, but it is not typically part of a standardized ventilator care bundle.
D. The position of the patient can affect ventilation and respiratory mechanics. In the context of ventilator care, positioning recommendations may include elevating the head of the bed (semi-Fowler's position) to reduce the risk of aspiration and improve lung expansion. Placing the client in a supine position alone is not specific to the ventilator care bundle but may be considered based on the patient's clinical condition.

A. The water temperature for handwashing should be comfortable and tolerable for the hands. Hot water can be drying to the skin and may not necessarily improve the effectiveness of hand hygiene. Ideally, the water temperature should be warm, but not uncomfortably hot or cold, to encourage thorough handwashing.
B. The amount of soap used for handwashing is important for effective cleaning. Applying 4 to 5 mL (approximately a teaspoon) of liquid soap ensures adequate coverage to create lather and effectively cleanse the hands. Too little soap may not produce enough lather to clean effectively, while too much may be wasteful.
C. During hand hygiene, it's recommended to keep the hands lower than the elbows to prevent water from running from the contaminated area (hands) to the cleaner area (elbows). This helps maintain hygiene and prevents potential contamination of the cleaned hands.
D. After washing hands with soap and water, it's important to dry them thoroughly. However, rubbing hands and arms to dry is not recommended. Instead, hands should be dried using a clean towel or paper towel. Rubbing can cause friction and potential irritation to the skin.

A. Indirect contact transmission occurs when a person touches a contaminated object or surface and then transfers the infectious agent to themselves by touching their own mucous membranes (such as mouth, nose, eyes) or broken skin. In this scenario, the client acquired the Staphylococcus aureus infection by touching a contaminated towel, which is an example of indirect contact transmission.
B. Airborne transmission involves the spread of infectious agents through droplet nuclei (small particles) that remain suspended in the air for long periods or are disseminated over long distances. Staphylococcus aureus infections are typically not transmitted through airborne routes unless they are associated with respiratory droplets, which is less common compared to other pathogens.
C. Droplet transmission occurs when respiratory droplets containing infectious pathogens (such as viruses or bacteria) are generated through activities like coughing, sneezing, or talking, and then deposited onto mucous membranes of nearby individuals. Staphylococcus aureus infections are not typically transmitted through droplet routes unless they are associated with respiratory colonization or infections.
D. Vector transmission involves the transfer of infectious agents from one host to another by a vector, such as mosquitoes, ticks, or other animals. Staphylococcus aureus infections are not transmitted through vectors; they primarily spread through direct or indirect contact with contaminated surfaces, equipment, or healthcare personnel.

A. An occurrence report, also known as an incident report, documents the details of any unexpected event that occurs during the client's care. This includes falls. It is important to document the incident accurately and promptly in the client's medical record to ensure that all relevant information is recorded. However, this should not take priority over timely escalation of the issue.
B. It is essential to notify the client's healthcare provider (such as the physician or nurse practitioner) about the fall incident. The provider needs to be informed about the client's condition after the fall, any injuries sustained, and any immediate actions taken.
C. The nurse who witnessed or discovered the fall incident is responsible for completing the occurrence report. It should be filled out by the nurse who directly assessed the client's condition after the fall, documented any injuries, and initiated appropriate interventions. Asking another nurse to complete the report may not accurately reflect the details and actions taken by the nurse who was directly involved.
D. Risk management may need to be informed about the fall incident, especially if it resulted in injury to the client. Risk management is responsible for assessing the circumstances surrounding the fall, identifying potential risks or contributing factors, and implementing strategies to prevent future incidents. However, contacting risk management is typically done after initial actions such as ensuring client safety, notifying the provider, and documenting the incident.

A. Ventilator-associated pneumonia (VAP) is a common HAI that occurs in patients who have been mechanically ventilated for an extended period. The presence of a ventilator increases the risk of introducing pathogens into the lower respiratory tract, leading to pneumonia.
B. Catheter-associated urinary tract infection (CAUTI) is an HAI that occurs due to the use of urinary catheters. Indwelling urinary catheters can introduce bacteria into the urinary tract, increasing the risk of infection.
C. Surgical site infections (SSIs) are infections that occur after surgery in the part of the body where the surgery took place. They are a significant cause of morbidity and mortality and are considered HAIs when they occur in healthcare settings.
D. Influenza acquired from a coworker is not typically considered a healthcare-associated infection. It is usually acquired in community settings rather than healthcare facilities.
E. Central line-associated bloodstream infections (CLABSIs) occur when bacteria or other pathogens enter the bloodstream through a central venous catheter. These infections are considered HAIs because they are associated with the presence of a central venous catheter used for medical treatment.

A. This disease is caused by the varicella-zoster virus and is transmitted via airborne particles. When an infected person coughs or sneezes, the virus can be inhaled by others.

B. This bacterium causes severe diarrhea and colitis. It is primarily transmitted through contact with contaminated surfaces or feces, not through the air.
C. Measles is a highly contagious viral disease that spreads through airborne transmission. The virus can linger in the air for up to two hours after an infected person coughs or sneezes.
D. This bacterium can cause various infections, including skin infections and pneumonia. It is mainly spread through direct contact with an infected person or contaminated surfaces, not through the air.
E. Caused by the bacterium Mycobacterium tuberculosis, TB is transmitted through airborne particles. When a person with active TB coughs, sneezes, or talks, the bacteria can be inhaled by others.