A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

A 10-year-old client who had an appendectomy

A 3-year-old toddler who has a broken elbow

A 4-year-old preschooler who had a tonsillectomy

A 4-day-old infant who had a repair of a birth defect

Answer and Explanation

The Correct Answer is D

Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.

Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.

Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.

Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.

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Correct Answer is C

Explanation

Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.

Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.

Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.

Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.

Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.

A. Urinary catheterization B. Malnutrition C. Multiple caregivers D. Chlorhexidine washes

Correct Answer is A

Explanation

Choice A reason: Urinary catheterization is a well-known risk factor for HAIs, particularly catheter-associated urinary tract infections (CAUTIs). The use of indwelling urinary catheters can introduce bacteria into the urinary tract and is associated with a significant proportion of HAIs.

Choice B reason: While malnutrition can affect the immune system and increase the risk of infections, it is not a direct cause of HAIs. Good nutritional status is important for wound healing and infection prevention, but it does not cause HAIs by itself.

Choice C reason: Having multiple caregivers can increase the risk of transmitting infections, especially if hand hygiene and other infection control practices are not consistently followed. However, it is not considered a direct cause of HAIs like urinary catheterization is.

Choice D reason: Chlorhexidine washes are actually used as a preventive measure against HAIs, particularly in reducing the risk of surgical site infections. They are not a cause of HAIs but rather part of the solution to prevent them.

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A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Correct Answer is C

Explanation

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Correct Answer is A

Explanation

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

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A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

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