A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections.

Exhibits

Select the three clients whose findings indicate the program is effective.

Client 1

Client 5

Client 2

Client 3

Client 4

Answer and Explanation

Correct Answer : B,C,D

A.   Client 1: Worsening of the pressure injury with purulent drainage indicates infection and failure of pressure injury prevention strategies.
B.   Client 5: The stage 3 pressure injury reduced in size and severity to stage 2, with the absence of purulent drainage, indicating wound healing and effective intervention.
C.   Client 2: WBC count decreased from 11,500/mm³ to within the normal range at 9,500/mm³, indicating improvement in pneumonia.
D.   Client 3: Temperature reduced from 38.9°C to 38°C, with stabilization of vital signs, suggesting improvement in the wound infection.
E.   Client 4: An increase in WBCs in the urine from 2 to 6 per low-power field suggests worsening of the urinary tract infection, indicating program ineffectiveness.

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Correct Answer is D

Explanation

A. Cover the site with a stockinette dressing: This action may help secure the IV site but does not immediately address the safety concern.
B. Administer a sedative: Administering sedatives is not the first-line intervention and requires a provider's order.
C. Apply a soft mitten restraint: Restraints should be the last resort after implementing less restrictive measures. Closer observation and attempts to redirect the client are less restrictive and should be tried first.
D. Place the client close to the nurses' station: Proximity allows for frequent monitoring, preventing further self-harm.

A. Applying the restraint over the client's gown B. Using a quick-release knot to secure the restraint C. Placing the restraint across the client's chest D. Tying the restraint to the bed frame

Correct Answer is C

Explanation

A. Applying the restraint over the client's gown: Restraints should be applied over clothing or a gown to prevent skin irritation and ensure comfort.
B. Using a quick-release knot to secure the restraint: A quick-release knot is the recommended method for securing restraints to ensure they can be removed quickly in an emergency.
C. Placing the restraint across the client's chest: Belt restraints should be placed around the waist, not the chest, as chest placement can impair breathing.
D. Tying the restraint to the bed frame: Restraints should be tied to the bed frame (not the side rails) to prevent injury during bed movement.

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A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections. Exhibits Select the three clients whose findings indicate the program is effective.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections.

Exhibits

Select the three clients whose findings indicate the program is effective.