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 A

Explanation

A. Reporting the findings to the healthcare provider is crucial in this situation. The combination of fever and dyspnea could indicate a serious complication such as aspiration pneumonia or an infection related to the tube feeding. Prompt communication with the healthcare provider ensures that the client receives timely evaluation and treatment.
B. While monitoring electrolytes is important in the context of tube feedings (to ensure proper balance and prevent imbalances), the symptoms of fever and dyspnea are more urgent concerns that need immediate attention.
C. Using an incentive spirometer can be beneficial for improving lung function and preventing complications like atelectasis, especially if the client has respiratory issues. However, this action is more appropriate for clients who have specific respiratory therapy needs and is not the first step in addressing acute symptoms like fever and dyspnea, which require a more immediate response.
D. Connecting the tube to low intermittent suction might be used to manage gastric residuals or to help with gastrointestinal decompression in some situations, but it does not address the acute symptoms of fever and dyspnea.

A. Increase fiber in diet and add daily prune juice. B. Assess type and frequency of physical activities. C. Perform a digital examination for fecal impaction. D. Check bowel sounds and abdominal tenderness.

Correct Answer is D

Explanation

A. Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B. Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C. A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D. Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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