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?
A client who has pneumonia after being on a ventilator
A client who has a bladder infection and has an indwelling urinary catheter
A client who has a surgical site infection
A client who has influenza acquired from a coworker
A client who has an infection at their central-line insertion site
Correct Answer : A,B,C,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is A
Explanation
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.
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