A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

A client who has dementia and is experiencing paranoia

A client who has a UTI and reports itching after receiving a dose of cefaclor PO

A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr

A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Answer and Explanation

The Correct Answer is B

A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.

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Correct Answer is C

Explanation

A. Administering pain medication before ambulation is an example of patient-centered care and pain management but does not specifically demonstrate fidelity, which relates to keeping promises and being trustworthy.
B. Stopping feeding when a client becomes short of breath is an appropriate response to prevent aspiration, but it is not an example of fidelity.
C. Telling a client she will return with a medication and following through with that commitment demonstrates fidelity by fulfilling a promise and showing reliability.
D. Dividing time and care between clients is part of effective time management, but it does not specifically represent fidelity, which emphasizes keeping promises to clients.

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it. B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill. C. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture. D. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster.

Correct Answer is C

Explanation

A. Placing a midstream urine sample in a specimen refrigerator is an appropriate practice and does not pose an infection control hazard.
B. Wiping a countertop with chlorhexidine solution is a correct practice following a blood spill and contributes to infection control.
C. Pouring sterile 0.9% sodium chloride irrigation solution directly onto an open pressure wound before collecting a specimen poses an infection control hazard, as it can introduce contaminants to the wound and affect the culture results.
D. Using alcohol-based antiseptic to clean hands after interacting with a client who has varicella zoster is an appropriate infection control measure and reduces the risk of spreading infection.

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A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

Explanation

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