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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Tie it to the bed frame with a quick release knot.This option is correct because securing the restraint to the bed frame ensures that the client cannot easily remove it, while a quick release knot allows for rapid removal in case of an emergency.

B. Strap the restraint with a square knot to the head of the bed.While a square knot may be secure, it is not considered a quick-release method, which is essential for the safety of the client.

C. Use a quick release knot to tie the restraint to the side rail.Tying a restraint to the side rail can pose a risk because if the side rail is lowered, it may create a situation where the restraint is loose or ineffective. It is safer to secure it to the bed frame instead.

D. Assist with range of motion at least every 3 hours.While providing range of motion is important to prevent complications from immobility, it does not address how to secure the restraint itself. Regular assessments and range of motion exercises should be part of the overall care plan but are not directly related to securing the restraint.

A. Droplet B. Enhanced contact C. Airborne D. Neutropenic

Correct Answer is C

Explanation

A. Droplet isolation:

Droplet isolation is used for diseases spread by respiratory droplets that are larger than those in airborne transmission. Examples include influenza and bacterial meningitis.

B. Enhanced contact isolation:

Enhanced contact precautions are implemented for patients known or suspected to be infected with pathogens that require additional control measures beyond standard precautions. This may include multi-drug resistant organisms.

C. Airborne isolation:

Airborne isolation is specifically used for diseases that are transmitted through small airborne particles that can remain suspended in the air for an extended period. Tuberculosis is one such example. The use of N95 respirators and negative pressure rooms is common for airborne precautions.

D. Neutropenic isolation:

Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low neutrophil counts. It involves measures to protect the patient from potential infections.

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The nurse would recognize which of the following patients would be at highest risk for developing an infection?

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