A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Instructing the client to wash minor wounds carefully

Assessing vaccination records for booster shot needs

Teaching hand hygiene to prevent the spread of microbes

Encouraging the client to eat a nutritious diet

Answer and Explanation

The Correct Answer is C

A.   Proper wound care is essential in preventing infections, particularly in older adults who may have thinner skin and slower healing processes. However, while this is important, it is just one aspect of a comprehensive infection prevention strategy and does not address broader systemic issues.
B.   Older adults are often at higher risk for infections due to waning immunity. Regular vaccinations, such as the flu vaccine, pneumococcal vaccine, and others, can significantly reduce the risk of serious infections. This action is critical but is part of a preventive framework rather than a standalone solution.
C.   Hand hygiene is one of the most effective measures to prevent the transmission of infections. Educating clients about proper handwashing techniques and when to wash their hands can significantly reduce the risk of infections, especially in older adults who may be more susceptible due to age-related immune changes.
D.   Nutrition plays a vital role in maintaining overall health and supporting the immune system. A well- balanced diet can help older adults fight infections more effectively. However, while important, diet alone may not be as immediately impactful in preventing infections as other measures like hand hygiene and vaccination.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Individuals with AB+ blood type can receive blood from any donor type (A, B, AB, or O) because they have no antibodies against A or B antigens. The safest practice is to provide the most compatible blood type, but AB+ recipients are considered universal recipients.
B. To minimize the risk of bacterial growth and transfusion reactions, packed red blood cells (PRBCs) should be transfused within 2 hours of starting the infusion. It’s important to monitor the patient closely during this time.
C. The first 15 minutes of a blood transfusion are critical for observing any immediate adverse reactions. The nurse should stay with the patient during this time to monitor vital signs and assess for any signs of a transfusion reaction.
D. A crucial safety step is to verify the blood product against the patient’s blood band with another registered nurse (RN). This helps prevent errors related to mismatched blood transfusions, which can be life-threatening.
E. Blood transfusion tubing should be primed with normal saline to ensure that the blood product flows properly and to maintain patency. Normal saline is used because it is compatible with blood products and does not cause hemolysis.

A. Airplane flights B. Dehydration C. Cold weather D. Illness E. Flashing light patterns on television

Correct Answer is ["A","B","C","D"]

Explanation

A. Airplane flights can trigger a crisis due to changes in altitude and decreased oxygen levels in the cabin. The lower atmospheric pressure and reduced oxygen can contribute to sickling of red blood cells, increasing the risk of a crisis.
B. Dehydration is a significant trigger for sickle cell crises. It can lead to hemoconcentration, making the blood more viscous and promoting sickling of the red blood cells. Maintaining hydration is crucial for preventing crises.
C. Exposure to cold weather can trigger vaso-occlusive crises in sickle cell patients. Cold temperatures can cause blood vessels to constrict, reducing blood flow and increasing the likelihood of sickling and pain episodes.
D. Any illness, particularly infections, can trigger a sickle cell crisis. Infections can lead to increased metabolic demand, dehydration, and inflammatory responses, all of which can contribute to vaso- occlusion and pain.
E. While certain sensory stimuli can affect individuals with various conditions (like migraines), flashing light patterns on television are not commonly recognized triggers for a sickle cell crisis. There is no substantial evidence linking this to vaso-occlusive events in sickle cell disease.

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A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are planning on transfusing a unit of blood. Which of the following are appropriate measures to take? (Select all that apply)

Correct Answer is ["B","C","D","E"]

Explanation

Which of the following factors are known to commonly trigger a crisis in patients with sickle cell disease? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

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