The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

Receiving immune suppressant therapy for cancer.

Has hyperemia at the site of an acute local infection.

Lost ten pounds adhering to a low carbohydrate diet.

Recently received a series of adult immunizations.

Answer and Explanation

The Correct Answer is A

A.   Clients receiving immune suppressant therapy, such as those undergoing treatment for cancer, are at a significantly increased risk for healthcare-associated infections. Immune suppressants weaken the body's ability to mount an effective immune response, making individuals more susceptible to infections.
B.   Hyperemia, or increased blood flow to a particular area, can be a sign of an acute local infection. While it indicates the presence of infection, the hyperemia itself does not increase the risk of developing a new or additional healthcare-associated infection.
C.   Weight loss, especially if associated with dietary changes, may affect overall health and nutritional status, potentially impairing wound healing and immune function. However, it is not as directly linked to an increased risk of HAIs as immune suppression or invasive procedures.
D.   Receiving vaccinations generally aims to enhance immunity and protect against specific infections. Immunizations can help prevent infections but do not increase the risk of healthcare-associated infections. This action is preventive rather than a risk factor for HAIs.

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Correct Answer is B

Explanation

A. While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B. Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C. Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D. Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.

A. "It is important to dress the right arm first." B. "Dressing must be a frustrating experience for you." C. "We will give you a class on dressing tomorrow." D. "This unit has a policy against staff harassment."

Correct Answer is B

Explanation

A. While providing practical advice is useful, this response does not directly address the client's current emotional state or frustration. The immediate need is to support the client emotionally rather than instructing them on dressing techniques. It may also come off as dismissive of the client’s feelings.
B. This response is the most appropriate because it acknowledges and validates the client’s emotional experience. By recognizing their frustration, the nurse shows empathy and understanding, which can help in building a therapeutic relationship. It also opens up a dialogue for the client to express their feelings and concerns, which can improve their overall comfort and cooperation.
C. While education on dressing techniques is beneficial, this response does not address the client's immediate frustration or emotional needs. It also postpones support and could make the client feel like their current struggles are not being adequately addressed in the moment.
D. This response is defensive and does not address the client’s immediate emotional needs. It may escalate the situation by making the client feel like they are being reprimanded for their behavior. It is important to handle such situations with empathy and support rather than focusing on institutional policies.

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The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

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Naxlex Comprehensive Predictor Exams

The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Correct Answer is B

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

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