A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Place immunocompromised clients in the same room.

Wash hands after removing gloves.

Use antimicrobial hand gel after refilling a client's water pitcher.

Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

Answer and Explanation

Correct Answer : B,C,D

The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

Choice A rationale:

Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.

Choice B rationale:

Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.

Choice C rationale:

Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.

Choice D rationale:

Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.

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Correct Answer is D

Explanation

The correct answer is choice d. Notify the charge nurse of the client’s concerns.

Choice A rationale:

Offering information about alternative therapies is not appropriate in this situation. The nurse’s role is to ensure the client understands the current procedure and to address their concerns, not to suggest alternatives unless directed by the healthcare provider.

Choice B rationale:

Contacting a family member to convince the client to change their mind is not ethical. The decision to proceed with surgery should be made by the client, based on their understanding and consent, not under pressure from family members.

Choice C rationale:

Telling the client the benefits of the surgery might be helpful, but it does not address the client’s lack of understanding about the procedure. The nurse should ensure the client has all the necessary information to make an informed decision.

Choice D rationale:

Notifying the charge nurse of the client’s concerns is the correct action. The charge nurse can facilitate further discussion with the surgeon to ensure the client receives the necessary information and support to make an informed decision. This ensures that the client’s autonomy and right to informed consent are respected.

A. "What types of foods have you been eating?” B. "Are you using stool softeners or laxatives?” C. "Have you been passing gas?” D. "Have you had small liquid stools?”

Correct Answer is D

Explanation

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

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A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

A nurse is preparing to administer medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

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