The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

A 60 year old patient who is on a mechanical ventilator

A 65 year old patient who is vegetarian and obese

A 45 year old patient who smokes a pack of cigarettes a day

A 70 year old patient who has a normal WBC count

Answer and Explanation

The Correct Answer is A

A. A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation. Ventilated patients are susceptible to ventilator-associated pneumonia and other respiratory infections, making them more vulnerable to HAIs.

B. A 65 year old patient who is vegetarian and obese: While obesity can increase the risk for certain complications, being vegetarian does not inherently increase the risk for HAIs. This patient may have some risk factors, but they are not as significant as those associated with mechanical ventilation.

C. A 45 year old patient who smokes a pack of cigarettes a day: Smoking is a risk factor for various health issues, including respiratory infections, but it does not specifically correlate with a higher risk of HAIs in a hospitalized setting compared to a patient on a mechanical ventilator.

D. A 70 year old patient who has a normal WBC count: Although older age can increase the risk for infections, a normal white blood cell count indicates a functioning immune response. Without additional risk factors, this patient would not be considered the most at risk for developing HAIs compared to a ventilated patient.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I will wear gloves and a gown when bathing a client who has open skin lesions.": This statement indicates an understanding of the appropriate use of personal protective equipment (PPE) in a situation where there is a risk of exposure to blood or bodily fluids. Wearing gloves and a gown helps protect the AP from potential pathogens present in the client's open skin lesions.

B. "I will wear gloves when measuring a client's blood pressure.": While it may be appropriate to wear gloves for certain procedures, it is not universally required to wear gloves when measuring blood pressure unless there are specific concerns about contamination or exposure to body fluids. This statement does not demonstrate a clear understanding of when gloves are necessary.

C. "I will wear gloves whenever I am in contact with clients.": This statement suggests a lack of understanding of the appropriate use of gloves. Gloves should be used when there is a risk of contact with blood, body fluids, or open wounds, but they are not necessary for all interactions with clients, especially if there is no risk of contamination.

D. "I will wear gloves to minimize the number of times I have to wash my hands.": This statement indicates a misunderstanding of the primary purpose of gloves. Gloves are used to protect both the caregiver and the client from infection, and hand hygiene should still be performed before and after glove use. The focus should be on infection control rather than convenience.

A. preventing the client from sliding in bed B. lubricating the area with skin cream C. improving the client's hydration D. pulling the client up from under the arms

Correct Answer is A

Explanation

A. Preventing the client from sliding in bed: This activity directly addresses shearing forces, which occur when the skin is pulled in one direction while the underlying tissues move in another. By preventing the client from sliding down in bed, the nurse can reduce the risk of shearing, thereby helping to protect the integrity of the skin and the existing pressure injury.

B. Lubricating the area with skin cream: While applying skin cream can help keep the skin hydrated and may assist in overall skin health, it does not directly prevent shearing forces. Lubrication is more about skin protection and moisture retention rather than reducing mechanical forces acting on the skin.

C. Improving the client's hydration: While maintaining good hydration is important for skin health and can aid in the healing process, it does not specifically address the mechanical forces that cause shearing. Proper hydration helps maintain skin elasticity but does not prevent movement-related injuries.

D. Pulling the client up from under the arms: This method can actually increase the risk of shearing forces and potential injury to the client. Instead, using a draw sheet or a transfer device to reposition the client helps to reduce friction and shearing when moving the client up in bed. Proper techniques should always be employed to minimize the risk of skin damage.

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The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

Correct Answer is A

Explanation

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