The nurse is aware that the patient most at risk for a health care-associated infection (HAI) would be the:
45-year-old in traction for a fractured femur.
56-year-old with pneumonia who is receiving oxygen by mask.
70-year-old with congestive heart failure attached to a monitor.
65-year-old with a Foley catheter.
The Correct Answer is D
Choice A rationale
A 45-year-old in traction for a fractured femur is at risk for infection due to immobility and potential surgical wounds, but not as high as someone with a Foley catheter.
Choice B rationale
A 56-year-old with pneumonia receiving oxygen is at risk for respiratory infections, but the presence of a Foley catheter significantly increases the risk of healthcare-associated infections.
Choice C rationale
A 70-year-old with congestive heart failure attached to a monitor has a risk of infection due to potential breaks in skin integrity, but not as high as someone with a Foley catheter.
Choice D rationale
A 65-year-old with a Foley catheter is at the highest risk for health care-associated infections because the catheter provides a direct pathway for pathogens into the urinary tract, increasing infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Asking the health care provider if they contaminated their glove and the sterile field is not the most effective response. The provider may not be aware of the contamination, and asking this question does not immediately address the contamination issue. Ensuring the sterile field remains uncontaminated is crucial in preventing infections.
Choice B rationale
Pointing out the possible break in surgical asepsis and providing another set of sterile gloves and a fresh sterile field is the best action. This ensures that the sterile environment is maintained, reducing the risk of infection and promoting patient safety.
Choice C rationale
Not saying anything because it is near the end of the procedure is unsafe. Even if the procedure is almost complete, any contamination can increase the risk of infection. It is essential to address the contamination immediately to ensure patient safety.
Choice D rationale
Reporting the health care provider for violating surgical asepsis and endangering the patient is not an immediate solution. While it is important to report such incidents for future prevention, the priority should be to address the contamination promptly to maintain the sterile field and protect the patient.
Correct Answer is C
Explanation
Choice A rationale
Normal flora does not function as cell rebuilders. They primarily exist in a symbiotic relationship with the host without directly participating in cell repair processes.
Choice B rationale
While some normal flora aid in digestion, they are not involved in blood production. Blood production is a function of bone marrow and not influenced by normal flora.
Choice C rationale
Normal flora play a crucial role in preventing the colonization of pathogens by competing for nutrients and space, thereby protecting the body from harmful microorganisms.
Choice D rationale
Normal flora do not manage the fluid balance of the body. Fluid balance is regulated by the kidneys and the body's endocrine system, not by the normal flora.
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