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Exhibits

Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

Check the patient’s temperature daily.

Keep the surgical dressing in place for the first three post-op days.

Encourage and assist with early ambulation.

Assess the need for the Foley catheter every shift.

Teach and encourage the use of an incentive spirometer.

Monitor laboratory values.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason:

Checking the patient’s temperature daily is crucial for early detection of infections. Fever is often one of the first signs of an infection, including Healthcare-Associated Infections (HAIs). Regular monitoring of temperature can help identify infections early, allowing for prompt intervention and treatment. This is particularly important for Mr. Johnson, who is at increased risk due to his recent surgery and the presence of a Foley catheter. Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C).

Choice B reason:

Keeping the surgical dressing in place for the first three post-op days is important for protecting the surgical site from contamination and infection. However, it is not necessarily a strategy to decrease the risk of HAIs beyond the initial postoperative period. The dressing should be changed according to the healthcare provider’s instructions to ensure the wound remains clean and dry. While this is a good practice, it is not as directly related to preventing HAIs as the other interventions.

Choice C reason:

Encouraging and assisting with early ambulation is vital for preventing postoperative complications, including HAIs. Early ambulation helps improve circulation, lung function, and gastrointestinal motility, reducing the risk of complications such as pneumonia and deep vein thrombosis (DVT). It also promotes overall recovery and reduces the length of hospital stay, which in turn decreases the risk of HAIs. Mobilizing patients early can help prevent respiratory infections and other complications associated with prolonged bed rest.

Choice D reason:

Assessing the need for the Foley catheter every shift is essential for preventing catheter-associated urinary tract infections (CAUTIs). Foley catheters are a common source of HAIs, and their use should be minimized whenever possible. Regular assessment of the necessity of the catheter can help ensure it is removed as soon as it is no longer needed, reducing the risk of infection. The CDC recommends removing catheters as soon as they are no longer necessary to prevent CAUTIs.

Choice E reason:

Teaching and encouraging the use of an incentive spirometer is an effective strategy for preventing postoperative respiratory complications, including pneumonia. Incentive spirometry encourages deep breathing and lung expansion, which helps prevent atelectasis and improves oxygenation. This is particularly important for postoperative patients who are at risk of developing respiratory infections due to immobility and the effects of anesthesia. Proper use of an incentive spirometer can significantly reduce the risk of respiratory HAIs.

Choice F reason:

Monitoring laboratory values is important for overall patient care but is not specifically targeted at preventing HAIs. Laboratory values can provide valuable information about the patient’s health status and help guide treatment decisions. However, they do not directly address the prevention of infections. While monitoring lab values is a good practice, it is not as directly related to HAI prevention as the other interventions listed.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A: Masking before interviewing a patient about health history
Masking is generally used when there is a risk of exposure to respiratory droplets, such as when a patient has a known or suspected respiratory infection. However, it is not typically required for a standard health history interview unless there is a specific risk of exposure to infectious agents.
Choice B: Gloving before wiping pink sputum off the bedrail
This is the correct answer. Standard precautions include the use of personal protective equipment (PPE) such as gloves when there is a potential for contact with blood, body fluids, secretions, excretions, or contaminated items. Wiping pink sputum off the bedrail involves contact with potentially infectious material, making gloves necessary to prevent the spread of infection.
Choice C: Applying goggles before helping a patient to ambulate in the hall
Goggles or face shields are used when there is a risk of splashes or sprays of blood, body fluids, secretions, or excretions. Helping a patient to ambulate in the hall does not typically involve such risks, so goggles are not usually required in this scenario.
Choice D: Gowning prior to delivering a food tray to a patient
Gowns are used to protect skin and clothing from contamination when there is a risk of exposure to infectious material. Delivering a food tray to a patient does not generally pose such a risk, so gowning is not necessary for this task under standard precautions.

A. 3% Saline B. Saline 0.45% C. Saline 0.9% D. Dextrose 10%

Correct Answer is C

Explanation

Choice A: 3% Saline
3% Saline is a hypertonic solution, meaning it has a higher concentration of solutes compared to the blood plasma. It is typically used in critical care settings for specific conditions such as severe hyponatremia or cerebral edema. Administering 3% Saline to a patient with a fluid deficit who requires isotonic fluid replacement would not be appropriate because it could lead to cellular dehydration and other complications due to its high osmolarity.
Choice B: Saline 0.45%
Saline 0.45%, also known as half-normal saline, is a hypotonic solution. It has a lower concentration of solutes compared to blood plasma and is used to treat patients with hypernatremia or those who need to be rehydrated without adding too much sodium. However, it is not suitable for isotonic fluid replacement because it can cause cells to swell and potentially burst due to the influx of water into the cells.
Choice C: Saline 0.9%
Saline 0.9%, also known as normal saline, is an isotonic solution. It has the same concentration of solutes as blood plasma, making it ideal for fluid replacement in patients with a fluid deficit. Normal saline is commonly used to expand the extracellular fluid volume without causing significant shifts in fluid between compartments. This makes it the appropriate choice for isotonic fluid replacement.
Choice D: Dextrose 10%
Dextrose 10% is a hypertonic solution used primarily for providing calories in patients who need parenteral nutrition or for treating severe hypoglycemia. It is not suitable for isotonic fluid replacement because its high glucose content can lead to osmotic diuresis and fluid shifts that are not desirable in patients needing isotonic fluids.

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Exhibits Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which infection control actions would the nurse include in the use of standard precautions?

Correct Answer is B

Explanation

Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

Correct Answer is C

Explanation

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Infection prevention strategies include:

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Exhibits

Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.