The nurse would recognize which of the following patients would be at highest risk for developing an infection?
74 year old female with malnutrition and a foley catheter in place
54 year old female admitted for chest pain observation
34 year old male admitted for seizure observation
78 year old male with right sided hemiplegia following a stroke
The Correct Answer is A
A. 74-year-old female with malnutrition and a foley catheter in place:
Malnutrition can weaken the immune system, making the individual more susceptible to infections. Additionally, the presence of a foley catheter increases the risk of urinary tract infections.
B. 54-year-old female admitted for chest pain observation:
Chest pain observation does not inherently increase the risk of infection.
C. 34-year-old male admitted for seizure observation:
Seizure observation does not inherently increase the risk of infection.
D. 78-year-old male with right-sided hemiplegia following a stroke:
While the hemiplegia following a stroke may pose mobility challenges, the presence of malnutrition and a foley catheter in option A puts the patient at a higher risk for infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wash the client’s face:
While washing the client's face might be part of general care, when specifically providing oral care for a client with dentures, the first step should be to don gloves to ensure infection control and safety.
B. Remove dentures:
Removing dentures may be a step in the oral care process, but it should come after donning gloves to maintain proper infection control measures.
C. Apply lubricant:
Applying lubricant might be necessary, especially if the client experiences dryness or discomfort, but it should follow the step of donning gloves.
D. Don gloves:
This is the first action because it is crucial to wear gloves before handling a client's dentures or engaging in any oral care procedures. Gloves protect both the nurse and the client from potential infections and ensure proper hygiene during care.
Correct Answer is C
Explanation
A. Palpation:
Palpation involves using the hands to feel for tenderness, masses, or abnormalities in the abdomen. It is typically performed after auscultation. This helps prevent stimulating bowel activity before listening to bowel sounds.
B. The order does not matter:
In the context of abdominal assessment, the order does matter. Following a specific sequence, such as inspection, auscultation, palpation, and then percussion, is recommended to ensure a comprehensive and accurate assessment.
C. Auscultation:
Auscultation involves listening to bowel sounds using a stethoscope. It is the next step after inspection. Listening to bowel sounds before palpation helps avoid artificially stimulating bowel activity.
D. Percussion:
Percussion involves tapping the abdomen to assess for the presence of fluid or air. While less commonly performed in routine abdominal assessments, it is usually the last technique after inspection, auscultation, and palpation.
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