A male client who was treated for a draining, infected wound and placed on contact precautions while hospitalized is being discharged to his home where he lives with his wife and adolescent son. Which information should the practical nurse (PN) reinforce with the family?

Require family members and visitors to wear a mask and gown when visiting the client.

Have the client stay in a room separate from the family with the door closed.

Use paper plates and disposable utensils for the client's meals and snacks..

Place soiled dressings in a plastic bag that can be tightly secured for disposal.

Answer and Explanation

The Correct Answer is D

A. Require family members and visitors to wear a mask and gown when visiting the client: Masks and gowns are needed in healthcare settings to prevent cross-contamination, but at home, strict use of personal protective equipment (PPE) is not typically necessary for a draining wound unless there is high-risk exposure. Basic hygiene is usually sufficient.
B. Have the client stay in a room separate from the family with the door closed: Isolation at home is generally not necessary unless the infection is highly contagious through casual contact. Emphasis should instead be placed on good wound care and proper hygiene practices.
C. Use paper plates and disposable utensils for the client's meals and snacks: There is no need to use disposable eating utensils. Normal dishwashing practices are adequate to prevent the spread of infection in a home environment, as long as proper cleaning is maintained.
D. Place soiled dressings in a plastic bag that can be tightly secured for disposal: Proper disposal of contaminated dressings in a sealed plastic bag prevents leakage and minimizes exposure to infectious materials. This practice protects household members from accidental contact with wound drainage.

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Correct Answer is C

Explanation

A. The amount of fluid the client drank today: Although fluid intake affects weight, daily weights are intended to reflect overall fluid and nutritional changes over time, not just today's intake. Monitoring intake is important but not the most critical factor in conducting daily weights consistently.
B. When the client wants to be weighed: While respecting the client's preferences is important for cooperation, clinical accuracy requires consistency in timing and conditions, not simply weighing at the client's preferred time.
C. When the client was last weighed: Knowing when the client was last weighed ensures consistency and accuracy for monitoring trends. Daily weights should be taken at the same time each day, ideally in the morning before eating and after voiding, to accurately track fluid balance and body mass changes.
D. The amount of food the client ate today: Food intake affects weight slightly, but the purpose of daily weights is to detect significant changes, such as fluid retention or loss. Weighing under consistent conditions matters more than focusing on the day's food intake.

A. Provide a Yankauer tip for oral suction. B. Swab the oral cavity with a washcloth. C. Support the head with a small pillow. D. Use oral swabs with normal saline.

Correct Answer is D

Explanation

A. Provide a Yankauer tip for oral suction: A Yankauer suction device is useful for clearing large amounts of oral secretions but is typically used when secretions are too excessive to manage with swabbing alone. In routine oral care for an unconscious client, gentle cleaning with swabs is safer and minimizes mucosal trauma.
B. Swab the oral cavity with a washcloth: Using a washcloth in an unconscious client's mouth can be unsafe because it is bulky, can cause trauma to delicate tissues, and increases the risk of aspiration if too much fluid or debris is present. Oral swabs are designed to be safer and more appropriate for this purpose.
C. Support the head with a small pillow: While supporting the head ensures comfort, it does not directly address the priority need of safely and thoroughly cleaning the oral cavity to maintain hygiene and prevent infection. Airway protection and thorough cleaning are the primary concerns during oral care.
D. Use oral swabs with normal saline: Using oral swabs moistened with normal saline is the best intervention because it gently cleanses the mucous membranes, maintains moisture, and reduces the risk of mucosal injury. Normal saline is safe and non-irritating, which is critical for unconscious clients at risk for aspiration and mucosal breakdown.

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A male client who was treated for a draining, infected wound and placed on contact precautions while hospitalized is being discharged to his home where he lives with his wife and adolescent son. Which information should the practical nurse (PN) reinforce with the family?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is implementing a nursing care plan that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

Correct Answer is C

Explanation

While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

Correct Answer is D

Explanation

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