A charge nurse is teaching a newly licensed nurse about health care-associated infections (HAIs). Which of the following should the nurse include in the teaching as examples of HAIS?

Blood pressure 86/46 mm Hg

A blood pressure of 86/46 mm Hg indicates hypotension. Hypotension can be a sign of inadequate perfusion and may lead to organ dysfunction if not promptly addressed. Immediate action may include reassessment of the client's hemodynamic status, fluid resuscitation if indicated, and consideration of vasopressor medications under provider orders.

Oxygen saturation 94% on 2 L via nasal cannula

Although the oxygen saturation of 94% is within the acceptable range (typically ≥ 92% for most clients),

it should be monitored closely as per the prescribed titration to maintain ≥ 92%. If the oxygen saturation drops below the target range, the nurse may need to adjust the oxygen flow rate or consider alternative oxygen delivery methods to ensure adequate oxygenation.

Prescription for the transfusion of 2 units of packed RBCs

Transfusion of packed red blood cells (RBCs) is indicated, suggesting the client may have significant anemia or ongoing bleeding requiring correction of hemoglobin levels. Immediate action involves verifying the blood product compatibility, initiating transfusion per protocol (including pre-transfusion assessments), and monitoring the client closely for any signs of transfusion reaction or complications during the transfusion.

Pulse rate 100/min, respiratory rate 28/min

Elevated pulse rate (tachycardia) and respiratory rate (tachypnea) can indicate physiological stress, inadequate oxygenation, or compensation for decreased cardiac output due to hypotension. These vital signs should be closely monitored for any worsening trends or signs of instability that may require immediate intervention, such as further assessment for hypovolemia or respiratory distress.

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.