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","B","D"]

Explanation

A. Document the client's statement in the medical record. Accurate documentation is essential to provide a complete record of the client's care and decisions.
B. Reinforce teaching about the purposes of the medications. Providing information can help the client make informed decisions and reconsider their refusal.
C. Tell the client they can take their medications later in the day. This may not be appropriate, depending on the medication schedule and therapeutic requirements.
D. Record non-administration in the client's medication administration record (MAR). This ensures an accurate medication history and alerts other providers to the missed dose.
E. Inform the pharmacy the client's medications will be wasted. Medications are not automatically wasted upon refusal; they can often be returned or rescheduled.

A. A newborn has respiratory distress and requires oxygen. B. A newborn has an Apgar score of 7 at 5 min after birth. C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth. D. A newborn receives a heel stick on the outer aspect of the heel.

Correct Answer is C

Explanation

A. A newborn has respiratory distress and requires oxygen: This is a clinical event requiring immediate intervention but not necessarily an error or unexpected event warranting an incident report.
B. A newborn has an Apgar score of 7 at 5 minutes after birth: An Apgar score of 7 is within a normal range and does not constitute an unusual or reportable incident.
C. A newborn receives erythromycin ophthalmic ointment 4 hours after birth: Erythromycin should be administered within 1 to 2 hours after birth to prevent neonatal eye infections. Delayed administration requires incident reporting.
D. A newborn receives a heel stick on the outer aspect of the heel: This is standard practice to prevent nerve and tissue damage during blood sampling and does not require an incident report.

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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 caring for a client who has refused medications. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

Correct Answer is C

Explanation

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.

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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.