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 A

Explanation

A. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.

A. Client 1 B. Client 2 C. Client 3 D. Client 4

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Client	Tag colour	Rationale
Client 1	Red	The significant blood loss and tourniquet application indicate immediate life-threatening injuries that are survivable with prompt intervention. The heart rate of 54/min is concerning for hypovolemic shock.
Client 2	Black	Fixed and dilated pupils, no pulse, and no spontaneous respirations indicate the client is deceased or has non-survivable injuries.
Client 3	Red	Disorientation, multiple lacerations with significant bleeding, and elevated heart and respiratory rates indicate hemodynamic instability requiring immediate intervention.
Client 4	Yellow	The client is stable, with a suspected arm fracture and minor abrasions. Treatment can be delayed without significant risk of deterioration.

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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

A nurse is contributing to the plan of care for a client who speaks a different language than the nurse. Which of the following interventions should the nurse include to facilitate communication with the client?

Correct Answer is A

Explanation

The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red. yellow, or black tag. A tag color may be assigned to more than one client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

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.