Week 1: Clinical Reasoning and Infection Control

The client needs blood drawn for a laboratory test. The lab technician dons clean gloves. This is an example of______________The technician rubs the antecubital area with an alcohol swab prior to venipuncture. This is an example of__________Both are considered______________Asepsis.

Donning clean gloves is a barrier (not client preparation, environmental control, or contact guidelines). Disinfecting the skin before venipuncture is an example of client preparation (not a barrier, environmental control, or contact guidelines). Both are considered medical (not surgical) asepsis.​

Which of the following is a direct mode of disease transmission? Droplet Vector Borne Airborne Vehicle Borne

Droplet Rationale: Droplet is a direct mode of disease transmission. Airborne, Vehicle and Vector Borne are indirect modes of disease transmission.

Identify the improper documentation present in the narrative document below by clicking on it.​

Experiencing nausea not relieved by prescribed antiemetic. Primary care provider notified and new medication prescribed.----------S Peters RN

Which pictures show practices that significantly reduce or prevent the spread of infection? Select all that apply. Donning personal protective equipment Using hand sanitizer Performing a surgical scrub Healthcare worker covering cough

using hand sanitizer Performing a surgical scrub

If the nurse has sterile gloves and gown on and is touching a non-sterile pen and clipboard, this violates which client care aspect of asepsis? Barriers Contact guidelines Client and equipment preparation Environmental controls

Contact guidelines

Complete the statements about the 24-hour clock using the drop-down menu to select the correct word or phrase.​ Each new day begins at__________and ends at___________on the same day. ​ Each expression of time using the 24-hour clock uses four digits. The_____________clock uses four numbers for all time and the____________clock uses the a.m./p.m. designation.

Each new day begins at 00:00 and ends at 23:59 on the same day. Each expression of time using the 24-hour clock uses four digits separated by a colon. The 24-hour clock uses four numbers for all time and the 12-hour clock uses the a.m./p.m. designation. Rationale: Each new day begins at 0000 and ends at 2359 on the same day. ​ Each expression of time using the 24-hour clock uses four digits.​ The 24-hour clock uses four numbers for all time and the 12-hour clock uses the a.m./p.m. designation.

The action seen in the image shown here is an example of ___________ asepsis.

Medical

Based on the assessment data, what is Mrs. Smith's primary physical issue right now? Weight loss Oral care Nutritional status Fatigue

Nutritional status Rationale: Mrs. Smith's highest physical priority right now, or main problem, is nutritional status. The cues related to fatigue and decreased mobility being the causes (etiology) include being unable to feed herself, brush her teeth, and limited range of motion in both shoulders. The cues that provide evidence of the nutritional problem include current weight, thick oral secretions, sores in the mouth, and halitosis.

Review the picture shown here. Which actions indicate a need for hand hygiene education? Select all that apply. Person washing hands. Left wrist touching faucet; right fingers touching left wrist. Fingers are pointing down Rinsing with running water Rubbing fingers on wrist Sleeves pushed above wrists Resting wrist against faucet

Rubbing fingers on wristResting wrist against faucet

Which types of asepsis eliminate all microorganisms?

Sterile surgical instruments

The nurse enters a client's room. Before they touch the client, they can use_____________o clean their hands. The nurse performs nursing care and their hands are visibly soiled. The nurse should then use___________to clean their hands.

alcohol based hand sanitizer Soap and water

What are the benefits of using an electronic health record (EHR) for the health professional? Select all that apply.​ Does not allow manual data entry Access to records anytime Continuity of care Remote access Ability to document clinical reasoning Data not secure All data is readily accessible

all data is readily accessible ability to document clinical reasoning access to records anytime remote access continuity of care​ Rationale: EHR does allow manual data entry. Data security is regulated to prevent personal health information being stolen.

Prioritize Mr. Stanton's areas of need based on priority for care at this time.

level 2: alcoholism and broken leglevel 3: unemployment Rationale: Based on the first, second, and third levels of priority for care, Mr. Stanton has no first-level care needs as he is not in imminent danger due to an emergent alteration in health. His alcoholism is a second-level problem, since his history of being combative when his blood alcohol content (BAC) is elevated puts him at risk for injury as he works to recover from the surgical repair of his broken leg. For his long-term health, finding a job and remaining sober are third-level priorities at this time.​ Keep in mind that, despite being a third-level priority in terms of physical health at this time, Mr. Stanton's unemployment does pose a long-term and ongoing threat to his safety, health, and wellness

Complete the nursing diagnosis statements below by dragging the diagnosis words/phrases to the corresponding etiology.​ Etiology Hospitalization BronchitisHypothalamic dysfunction Hypovolemia Low-fiber diet

look at photo Rationale: Remember, in its simplest form, a nursing diagnosis contains a problem (diagnosis) and a reason the problem is happening (cause or etiology) joined by "related to."

The nurse is taking care of four clients on a surgical floor. Which client is most at risk of developing a healthcare-associated infection? A 35-year-old client who has an indwelling urinary catheter A 50-year-old client who smokes a pack of cigarettes daily A 60-year-old client who is a vegetarian An 80-year-old client who has impaired mobility

A 35-year-old client who has an indwelling urinary catheter

The surgical nurse places sterile drapes on the operating room table to lay sterile instruments on the drapes. This is an example of which client care aspects of asepsis? Select all that apply. Client and equipment preparation Contact guidelines Environmental control Barrier

Barrier Client and equipment preparation Contact guidelines

According to the Centers for Disease Control and Prevention (2017), when can you use hand sanitizer instead of soap and water? Select all that apply. After removing gloves Before and after direct client contact Prior to using the restroom After potential exposure to an infectious disease If hands are visibly soiled

Before and after direct client contact After removing gloves

When creating a concept map, in which box is the main idea or concept placed? Box 1 Box 2 Box 3 Box 4

Box 1 Rationale: The main idea or central concept is placed in the center of the concept map, or Box 1 on the diagram. When constructing a nursing plan of care concept map, the central idea is the problem statement expressed as a nursing diagnosis.​ The remaining boxes are used to identify related sub-concepts, like subjective and objective data, test results, goals of care, and planned interventions.​

A client was just diagnosed with a catheter-associated urinary tract infection (CAUTI). What causes this? Urinary retention Client's immune system Overuse of antibiotics Break in sterile technique

Break in sterile technique Rationale: CAUTI can be caused by a break in sterile technique during the insertion of the catheter. Overuse of antibiotics and a decreased immune system can contribute to a higher infection risk but do not directly cause CAUTI. Urinary retention is a reason a catheter would be placed.

How could this breach of confidentiality have been prevented?​ Select all that apply. Use the cover sheet to list intended recipient(s), the sender, and the phone and fax numbers. Compare the number dialed to the confirmed number on the fax cover sheet before hitting the send button. Use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. Verify the fax number on the transmittal confirmation sheet. Confirm the fax number is correct before sending.

Confirm the fax number is correct before sending. Compare the number dialed to the confirmed number on the fax cover sheet before hitting the send button. Rationale: In this example, prevention would involve double-checking that the correct fax number of the recipient is correctly placed on the fax cover sheet and double-checking the number typed into the fax machine before hitting the send button. Use of the cover sheet will not prevent mistyping the recipient's fax number, though it can get the fax to the correct recipient more quickly. Programmed speed-dial keys are helpful for frequently dialed numbers, though that may not have applied in this example. Checking the transmittal confirmation sheet to compare the fax number may have meant the error would be discovered sooner, but it would not have prevented it from being sent to the incorrect number.

Maria was hospitalized for a few days and then went home to recover.

Convalescence Rationale: During convalescence, the symptoms decrease and the disease disappears. The host returns to a state of health.

______________ related to _________________________ as evidenced by watery stool with blood present, ______________________, increased skin turgor, and dry, oral mucous membranes.

Deficient fluid volume related to gastroenteritis as evidenced by watery stool with blood present, orthostatic hypotension, increased skin turgor, and dry, oral mucous membranes. Rationale: When stating the nursing diagnosis, it is not necessary to include every symptom present, just those that provide the best evidence to support the problem. The nature of the stool and timing of symptoms support gastroenteritis as the probable cause of Jim's symptoms, and the nature of the symptoms indicates dehydration is the cause. If this seems challenging, take a deep breath and relax. What you are learning is challenging you to pull information learned in previous courses and relate it to an individual in a new way. The intent of these questions is not to determine how quickly you can make a decision, but how well you are thinking.

The nurse needs to take stitches out before the client is discharged. Prior to touching the client, the healthcare provider uses hand sanitizer to___________ their hands. The nurse opens a steam-sealed package that contains _________________nstruments used for stitch removal. After the stitches are removed and the client is discharged, environmental services is called to use ultra-violet (UV) light to______________ the room

Disinfect Sterilized Decontaminate

The nurse was inserting an intravenous (IV) catheter and the needle punctured her glove and finger. What should be the nurse's first action? Tell the client about the exposure. Notify the supervisor after inserting the IV. Wash the hands with soap and water. Dispose of the IV needle in a sharps container.

Dispose of the IV needle in a sharps container. Rationale: The correct steps are: Stay calm and dispose of sharp (if a sharp was involved). Wash needlestick and/or cuts with soap and water. Flush splashes to the nose, mouth, or skin with water. Irrigate eyes with clean water, saline, or sterile irrigates. Report the incident to your supervisor and fill out the necessary incident forms. Seek medical treatment immediately. Post-exposure prophylaxis may be needed. There is no need to notify the client or document it in the client's chart.

Match the definition to the correct term.​ A longitudinal record of an individual's interactions with the healthcare system. The legal record documenting a single encounter between an individual and a healthcare professional.

EHR A longitudinal record of an individual's interactions with the healthcare system.- EMR The legal record documenting a single encounter between an individual and a healthcare professional. Rationale: The electronic medical record (EMR) is documentation of a single encounter between an individual and a healthcare professional. The electronic health record (EHR) is a longitudinal record of the individual's encounter with multiple health professionals within the healthcare system. For this reason, the electronic health record is a more comprehensive account of the total health history of an individual, since it includes every visit between the client and multiple health professionals. The complete accuracy of the EHR, however, is dependent on health professionals using the same informatics system when documenting. Fortunately, the transfer of medical information electronically allows for efficient sharing of health information in times of need with the person's permission.

Select the priority assessment data that, when considered together, can be used to form a hypothesis of what is happening in Jim's body by clicking on the word or phrase in the nurse's documentation. Subjective data: Jim and his family attended a picnic yesterday at noon. Abdominal pain and cramping with nausea and watery stool began around 6 p.m.; low-grade fever and bloody diarrhea 2 hours prior to arrival; seeks treatment due to blood in stool and not being able to keep any fluids down. His spouse has the same symptoms. Objective data: Temperature 100.6° F; HR 119 bpm; RR 26; BP 116/72 sitting, 100/58 standing; O2 sat 99% on room air; skin warm to touch, dry, skin turgor > 3 seconds; oral mucous membranes pale, dry, and intact; bowel sounds high-pitched and hyperactive.

Abdominal pain and cramping watery stool began around 6 p.m. bloody diarrhea not being able to keep any fluids down. Temperature 100.6° F HR 119 bpm RR 26 BP 116/72 sitting , 100/58 standing skin turgor > 3 seconds

What Gets Mapped Next? After adding health history data, what is the next step for the nursing student creating a concept map of assessment data? Re-assess client to fill identified gaps Identify meaningful connections between the assessment data Revise the concept map Add subjective and objective data

Add subjective and objective data Rationale: After adding data to the first sub-concept container, the nurse completes adding data to the remaining sub-concept containers before re-assessing the client to fill relevant gaps in knowledge, making connections between relevant data and the main concept, and revising the concept map, as needed. At each stage, the use of critical thinking to create the map strengthens the critical thinking and knowledge use skills of the student, increasing their success in school and their ability to provide safe and effective care.

Knowing that the fever is, most likely, the result of a sore throat, Nadine decides to help Sheila feel better and get back to sleep. Place the actions in the order Nadine should complete them, starting with the first. Call the healthcare provider. Sit with Sheila until she falls asleep. Administer acetaminophen and apply a cold compress. Check Sheila's temperature in a few hours.

Administer acetaminophen and apply a cold compress. Sit with Sheila until she falls asleep. Check Sheila's temperature in a few hours. Call the healthcare provider. Rationale: Since it is the middle of the night and Sheila's illness is a level-two priority, Nadine starts with actions that will help Sheila feel better and get back to sleep. These measures include giving antipyretic medication (acetaminophen), placing a cool cloth on the forehead, and staying near while she falls asleep. As long as the comfort measures help, Nadine knows she can wait until morning to contact the healthcare provider after checking Sheila's temperature and seeing how she is feeling.

Drag Mr. Stanton's assessment data to the appropriate container. Some choices may apply to more than one container. Reason for seeking care: Health history: Subjective data: Objective data:

Reason for seeking care: Rehabilitation care post internal fixation of L femoral fracture Health history: Alcoholism Subjective data: Unemployed, can't keep a job due to alcoholism, drinking since age 13 (30 years total), now consumes a fifth of whiskey every 2 days, wants to stop drinking but has failed in the past; asking questions about plans for rehabilitation and getting back to work, pain currently 3/10 Objective data: Blood alcohol content 200 mg/dL; found at rest stop combative and mumbling; now alert and oriented, speech clear, responds to questions appropriately, last dose of pain medication 45 minutes prior to arrival At this time, Mr. Stanton's assessment data is missing quite a bit of information. Based on your knowledge of health assessment, what further assessment data related to his leg injury and repair is needed at this time? More information to come on this, so keep your notes close.

Read each scenario and use the drop-down menus to indicate if the situation presents a potential breach of confidentiality by selecting either Risk Present or No Risk Present. The fax machine is in an open hallway accessible to anyone on the floor. Colleagues discussing a client in a conference room with the door open to a busy hallway. Colleagues use encrypted email when sending information about clients. A nurse texting a friend that someone they saw last night at a restaurant just came to their medical office. Colleagues following the organization's social media policy.

Risk Present The fax machine is in an open hallway accessible to anyone on the floor. Colleagues discussing a client in a conference room with the door open to a busy hallway. A nurse texting a friend that someone they saw last night at a restaurant just came to their medical office. No Risk Present Colleagues following the organization's social media policy. Colleagues use encrypted email when sending information about clients.

Which of the following are considered the body's natural defenses against infection? Select all that apply. Bad bacteria in the genitourinary system Saliva and tears Cilia lining the airway Low acidity gastric secretions Intact skin and mucous membranes

Saliva and tears Cilia lining the airway Intact skin and mucous membranes

This is Nadine, a mother caring for her family while her partner is out of town. It is 3 a.m. and Nadine hears her 6-year-old, Sheila, call out. As she enters the room, she sees Sheila sitting in bed, crying. When asked what is wrong, Sheila says her head, stomach, and throat hurt. As Nadine strokes her daughter's forehead, she notices the skin is warmer than usual and slightly red. Select the cues that, when considered together, can explain what may be causing Nadine's daughter to feel sick. Crying Headache Stomachache Sitting in bed Warm skin Red cheeks Sore throat Not sleeping

Headache Stomachache Warm skin Red cheeks Sore throat Rationale: From a pathophysiologic perspective, the red cheeks and warm skin are both associated with inflammation and infection—that is what places them in this cluster of cues. Of course, a sore throat, stomachache, or headache could be due to inflammation or infection, as well as being the reason for warm skin and red cheeks, and are in the cluster of cues as well. As for not sleeping, sitting up in bed, and crying, these are cues of how poorly Sheila is feeling and present strong evidence that something is wrong. But these cues do not offer a cause of what is wrong without collecting more data.

Use the drop-down menus to complete the nursing diagnosis for Keeshia. Ineffective __________ related to _________ as evidenced by ___________, and maxillary sinus tenderness.

Ineffective airway clearance related to possible sinus infection as evidenced by thick, green drainage from nose, nasal congestion, and maxillary sinus tenderness.

Why can't multiple family members of a client be present in the operating room? It violates barriers. It violates environmental control. It violates contact guidelines. It violates client and equipment preparation.

It violates environmental control.

Keeping instruments in sealed packages before (not during or after) use is part of surgical (not medical) asepsis or sterile (not clean) technique. The packaging prevents contamination (not decontamination or elimination) of supplies.

Keeping instruments in sealed packages before (not during or after) use is part of surgical (not medical) asepsis or sterile (not clean) technique. The packaging prevents contamination (not decontamination or elimination) of supplies.

Prevention of transmission is centered around breaking the chain of infection. Match each link in the chain of infection to its description. : Ways in which the infectious agent is spread from the reservoir to the susceptible host : Place in which infectious agents live, grow, and reproduce : Ways in which the infectious agent enters the susceptible host : Ways in which infectious agent leaves the reservoir : Individuals may have traits that affect their susceptibility and severity of disease : Microorganisms capable of causing disease or illness

Mode of Transmission: Ways in which the infectious agent is spread from the reservoir to the susceptible hostReservoir: Place in which infectious agents live, grow, and reproducePortal of Entry: Ways in which the infectious agent enters the susceptible hostPortal of Exit: Ways in which infectious agent leaves the reservoirSusceptible Host: Individuals may have traits that affect their susceptibility and severity of diseaseInfectious Agent: Microorganisms capable of causing disease or illness

The nurse is using soap and water to clean hands prior to client care. Proper hand hygiene is a nursing intervention that can break which links in the chain of infection? Select all that apply. Mode of transmission Susceptible host Reservoir Portal of entry Portal of exit Infectious agent

Mode of transmission Reservoir Portal of entry Portal of exit Rationale: Proper hand hygiene will break the chain at the portal of exit, mode of transmission, and portal of entry.For example, if a nurse has bacteria already on their hands (reservoir and portal of exit), then the bacteria will be washed off; it will not be transmitted. If the hands are clean, then there is no portal of entry unless the skin is broken. Hand soap is not used to sterilize and kill an infectious agent. It does not prevent hosts from being susceptible. ​

In what way do clients benefit when receiving care from a nursing student who used concept mapping to plan their care? Receive care from a nursing student who can follow the rules Helps nursing students be organized in a linear fashion Healthcare team is focused on medical diagnosis More holistic care that incorporates all aspects of the person

More holistic care that incorporates all aspects of the person Rationale: The nursing process and nursing care plans, while the heart of nursing practice, are linear processes designed to define the profession and communicate nursing's contribution to the holistic care of those with alterations in health.​ Yet, nursing itself is as complex and dynamic as the clients receiving nursing care. Concept mapping shifts the process of planning care from the traditionally linear nursing care plan to a visual image of the entire client information, allowing the nursing student to see the whole person, the overall status of their health, and the care needed to help them attain their health goals.​

Multiple people were diagnosed with salmonella infection after attending a family picnic where they ate the same contaminated food. The nurse knows that this type of infection is transmitted by_______ ________ contact

Multiple people were diagnosed with salmonella infection after attending a family picnic where they ate the same contaminated food. The nurse knows that this type of infection is transmitted by indirect, vehicle-borne contact. Rationale: Vehicle-borne infections are transmitted indirectly through contaminated food or water.

After investigating further, Nadine has a short list of what may be causing Sheila's fever. Which finding is most likely responsible? Sheila says her head hurt when she woke up and that it is already feeling better. Nadine observes that the back of Sheila's throat is swollen and red with patches of white. Sheila mentions that it hurts when she swallows. Sheila admits she ate two candy bars after going to bed.

Nadine observes that the back of Sheila's throat is swollen and red with patches of white Rationale .

After treatment with intravenous fluids and medication to lessen the cramps, Jim is discharged from urgent care and told to follow up with his primary care provider within two days. A nurse from the urgent care center called Jim the next day to check on his recovery. What cues will the nurse ask about to determine if Jim's status is improving? Select all that apply. Number of bowel movements Status of the rest of the family Whether the fever is gone Presence of abdominal pain Plans to return to work

Number of bowel movements Whether the fever is gone Presence of abdominal pain Rationale: The cluster of cues used to identify Jim's alteration in health is used by the nurse to evaluate how well he is recovering. These include fewer stools that are free of blood and becoming more formed, the absence of abdominal pain, and the presence of fever. While inquiring about Jim's spouse and plans to return to work would not be unusual, that information does not directly indicate if his presenting signs and symptoms are resolving.

Examine the picture shown here. Which clues indicate a need for review of hand hygiene? Select all that apply. Person with pink fingernails that extend 0.5 inches beyond the tip of their fingers using a brush and soap to wash their hands at a sink. Nurse has nail polish on. Nurse is using a scrub brush. Nurse removed rings. Nurse's nails are too long. Nurse is using soap.

Nurse has nail polish on. Nurse's nails are too long.

A client needs a cesarean section to deliver a baby. This procedure requires a sterile approach by the operating room staff. Which attire should the nurse don? Select the correct image below.

Nurse wearing gown, gloves, mask, and head cover.

Yesterday, the client was fine but today the client has developed a low-grade fever and complains of fatigue. The nurse should interpret these findings as indicating which stage of infection? Convalescence Prodromal Incubation Illness

Prodromal

Maria waited a couple of days hoping she was just tired, but a fever developed.

Prodromal Rationale: The prodromal stage is the interval from the onset of first symptoms to specific disease symptoms in which the infectious agent can be spread to others.

What is the primary reason for using asepsis? Eliminate all microorganisms. Protect the client and the healthcare provider. Protect the client. Keep the environment sterile.

Protect the client and the healthcare provider.

Jewelry should be minimally worn or not worn at all. What are the reasons for this recommendation? Select all that apply. Diamonds react with hand sanitizer. Sharp edges may puncture gloves. Soap can cause jewelry to tarnish. Grooves provide more areas for microbes. Bands are harder to clean than diamonds.

Sharp edges may puncture gloves. Grooves provide more areas for microbes.

Additional Health History Findings for Mrs. Smith While completing the admission assessment with Mrs. Smith, the nurse collects information on the client's health history. Which findings should be included in the health history container of the concept map? Select all that apply. Mrs. Smith eats a plant-based diet with limited animal proteins. Mrs. Smith is a type 2 diabetic. Mother died of a heart attack at age 49. Sister diagnosed with peripheral arterial disease (PAD). Twin brother died of complications from a viral illness.

Sister diagnosed with peripheral arterial disease (PAD). Mrs. Smith is a type 2 diabetic. Mother died of a heart attack at age 49. Rationale: Items from health history to include on the concept map include comorbid conditions and family illnesses similar in nature to the client's. For Mrs. Smith, this includes diabetes and the two genetically related relatives with vascular disease (heart attack and peripheral arterial disease [PAD]) as these may indicate a genetic predisposition to circulatory issues, including clotting, in family genetics. Although of interest to the overall assessment, the twin brother's illness and Mrs. Smith's healthy eating habits are not significant to her current rehabilitation needs. If this is frustrating, take a deep breath and let it out with a sigh. As a novice nursing student, your thought processes and critical thinking skills are growing as you gain more knowledge, such as clustering cues and concept mapping. With practice, this will become second nature.

The nurse finished caring for a client in isolation with an infectious respiratory illness. Which of the following types of hand hygiene can the nurse safely complete to reduce the risk of infection spread? Soap and water 40% alcohol-based hand sanitizer 20% alcohol-based hand sanitizer 60% alcohol-based hand sanitizer Water

Sixty percent alcohol-based hand sanitizer may be used for this situation. Soap and water is always an optimal choice.

When pouring a liquid, which parts are considered sterile? Review the image shown here and classify which parts are sterile and non-sterile. Inside of container Outside of container Outside of cap Inside of cap Outside of cup Inside of cup Liquid Lip of container

Sterile Inside of container Lip of container Inside of cap Liquid Inside of cup Outside of cup Non-Sterile Outside of container Outside of cap

The nurse needs to sterilize a set of surgical instruments. What methods could the nurse use? Select all that apply. Boiling water Combination of heat and pressure Gas Hand sanitizer Disinfectant spray Radiation Antiseptic soap

Sterilization can be done with moist heat, a combination of heat and pressure, gas, radiation, and boiling water.

Indicate which data collected by the nurse about Keeshia is subjective and which is objective by dragging each to the correct location. Tender maxillary sinuses Feels tired Sore throat Fever ended last night Thick, green discharge Headache Non-palpable lymph nodes

Subjective: Feels tired Sore throat Fever ended last night Thick, green discharge (reported by the patient as occurring in the morning) Headache Objective: Tender maxillary sinuses Non-palpable lymph nodes

A client on broad spectrum antibiotics is now diagnosed with Clostridium difficile, an infectious diarrhea. What describes the link between antibiotics and Clostridium difficile? The antibiotics kill the bad and good bacteria in the intestines. Clostridium difficile is a good bacteria in the body and antibiotics promote it. Antibiotics decrease inflammation and white blood cell count. The antibiotics increase the pH of the intestinal enzymes.

The antibiotics kill the bad and good bacteria in the intestines. Rationale: The antibiotics kill the bad and good bacteria in the intestines, thus breaking down the defenses in the gastrointestinal (GI) tract. This puts the client at risk of a new infection. Clostridium difficile is a bacteria that some people carry, but is not necessarily "good" bacteria.

A nurse is performing hand hygiene after providing client care. Place the steps for handwashing in the correct order from first to last. Dry the hands with a paper towel. Scrub hands, fingers, and wrists for 20 seconds. Wet the hands with clean, running water. Rinse thoroughly with water flowing toward the fingertips. Turn off the water with a different paper towel. Use liquid soap to lather the hands. Remove all jewelry.

The correct order is: Remove all jewelry. Wet the hands with clean, running water. Use liquid soap to lather the hands. Scrub hands, fingers, and wrists for 20 seconds. Rinse thoroughly with water flowing toward the fingertips. Dry the hands with a paper towel. Turn off the water with a different paper towel.

The__________in the picture shown here, is(are) an example of_____________It is a barrier that___________microorganisms and___________Transmission

The gloves (not cloth), in the picture shown here, are an example of medical asepsis (not surgical asepsis). It is a barrier that reduces (not eliminates) microorganisms and minimizes (not stops) transmission.

A nurse is scrubbed in on a procedure in the operating room. They have a sterile gown and sterile gloves. Their mask, eyewear, and head covering are not sterile. Which action demonstrates following contact guidelines? The nurse touches the gown sleeve, then the mask. The nurse touches the gown sleeve, then the head covering. The nurse touches the gloves, then the gown. The nurse touches the gloves, then the eyewear.

The nurse touches the gloves, then the gown.

Which statement is an accurate description of medical asepsis? Instruments are sterilized using steam. The nurse dons sterile gloves before placing a urinary catheter. The nursing assistant washes their hands with sanitizer. A sterile field is set up for a biopsy.

The nursing assistant washes their hands with sanitizer.

What factors impact the nurse's ability to recognize and cluster clinical cues? Select all that apply. Placing higher value on subjective data Understanding of pathological changes within the body Experience in the clinical setting Ability to identify a single, significant cue and follow up Knowledge of normal human anatomy

Understanding of pathological changes within the body Experience in the clinical setting Ability to identify a single, significant cue and follow up Knowledge of normal human anatomy Rationale: The ability of the nurse to quickly and accurately cluster cues is based on the knowledge of what is normal and not normal within the body from anatomy and physiology (normal) and pathophysiology (abnormal) courses. The presence of a single abnormal finding triggers the examiner to search for related cues that are often present at the same time. Over time and with experience, the examiner begins seeing the data clusters as a group, rather than as individual cues. ​ For a complete picture of an individual's health, the nurse values both subjective and objective data. When the two disagree, the cues that are measurable and observable (objective) are more strongly considered.

For each scenario below, select the correct type of hand hygiene: antiseptic hand wash or antiseptic hand rub. Antiseptic Hand Wash Antiseptic Hand Rub Hands have dirt on them Before assessing a client Contact with a client who has infectious Clostridium difficile After moving a client's belongings After removing gloves

Use an antiseptic hand wash when: hands are visibly soiled client has suspected infectious diarrhea you are exposed to Clostridium difficile and Bacillus anthracis Use an antiseptic hand rub: immediately before touching a client before performing an assessment when moving from a contaminated body site to a clean body site during client care after touching a client or the client's immediate environment after contact with blood, body fluids or contaminated surfaces after removing gloves

Vital signs

Weight: 100 lbsLimited range of motion bilateral shoulders; non-ambulatory, can transfer from chair to bed using walker; unable to stand on left leg; left arm weak; Ms. Smith is left-handed. Rationale: The observations of the nurse are objective data. The observations related to Mrs. Smith's rehabilitation potential include: weight 100 lbs; limited range of motion bilateral shoulders; non-ambulatory, can transfer from chair to bed using a walker; unable to stand on left leg; left arm weak; Ms. Smith is left-handed. The vital signs are normal and should not interfere with her rehabilitation potential. The mouth sores can be treated and will not interfere with her physical rehabilitation. Mrs. Smith's slow, quiet speech is reflective of her personality and should not impact her rehabilitation potential.

During a follow-up assessment of an individual recently discharged from the hospital, which cues, when clustered, indicate the client is at risk for ineffective health maintenance? Select all that apply. When asked how long they have had high blood pressure, the individual says they don't have that. The individual requests information about their illness. The person accurately lists the symptoms of asthma that indicate use of the rescue inhaler is needed. The person is unable to recall the reason they are taking two of their prescribed medications. A person with diabetes shares that they are following a plant-based diet to help with glucose control.

When asked how long they have had high blood pressure, the individual says they don't have that. The person is unable to recall the reason they are taking two of their prescribed medications. Rationale: Being unable to recall the reason for taking prescribed medications and denying a valid medical diagnosis indicate the client is at risk of not following the treatment plan to maintain their health. Health maintenance refers to a person's ability to take care of themselves and requires knowledge of their health status and current conditions, an understanding of why they are taking medications and what to expect as a result, and lifestyle choices that can improve their health. A person who knows what they don't know and asks questions is not at risk for ineffective health maintenance.

Using the drop-down menus, select the label for each container that best indicates the type of assessment data that will be added. Yellow box: Purple box: Blue box:

Yellow box: Health History​Purple box: Subjective Data​ Blue box: Objective Data Rationale: The three containers will have additional information related to Mrs. Smith's health that is pertinent to the assessment step of the nursing process, and the names should be broad enough that a variety of related information can be added to each container. The health history label is broad enough to include both the review of systems and family history data that is relevant to her recent stroke. Subjective data will include what Mrs. Smith tells you about her known allergies (which cannot be verified), but not her current medications (which can be verified). Objective data will include vital signs and physical assessment findings.

Select the objective data present in the documentation below.​

admitted from ED alert and oriented moderately short of breath T 98.4° F (36.9° C) HR 102 RR 23 BP 140/92; SaO2 92% on RA skin warm/dry, no lesions PERRLA bilateral crackles in lungs; heart rate/rhythm regular with occasional irregular beat JVD present bilateral pedal edema abdomen soft, bowel sounds active​ Rationale: Objective data includes: admitted from ED alert and oriented moderately short of breath T 98.4° F (36.9° C) HR 102 RR 23 BP 140/92; SaO2 92% on RA skin warm/dry, no lesions PERRLA bilateral crackles in lungs; heart rate/rhythm regular with occasional irregular beat JVD present bilateral pedal edema abdomen soft, bowel sounds active​ Subjective data, which can be a bit trickier, includes: stating they are "moderately diabetic" lives alone in assisted living pain level and that it occurs with deep respiration and last bowel movement Why is subjective data tricky? The medical record can reveal if a health provider has diagnosed the client with pre-diabetes and a family member could verify living arrangements. However, until verified, it remains subjective data.​ It is important to not get distracted by classifying information "correctly" when documenting. Instead, focus on getting information recorded as factually as possible.​

Keeshia, a 43-year-old female, presents to urgent care with a cold that she "just cannot get rid of." The discharge is thick green and accompanied by nasal congestion. These symptoms have been present for four days and are accompanied by a headache, sore throat and fever of up to 100.7° F. Further details of the history reveal that her nasal discharge is thick green in the morning and clears as the day progresses. Keeshia reports that she also has a morning cough that is productive of the same green sputum. Her fever finally went away last night, but she still feels tired and wiped out. Keeshia's exam revealed vital signs within normal limits. At the time of examination, her nasal mucosa is inflamed with clear nasal discharge. The maxillary sinuses are mildly tender. She has no swollen lymph nodes in her neck and her lungs are clear.

discharge is thick green headache sore throat fever of up to 100.7° F maxillary sinuses are mildly tender still feels tired and wiped out.

Using the drop-down menus, select the body system or location that is impacted by the cues indicated.

first: Neurologic Second: Respiratory Third: Cardiovascular Rationale: An elevated temperature is associated with infection, which can occur in any body system. A decrease in oxygen saturation may result from a decreased level of consciousness (neurologic), pneumonia (respiratory), and low blood pressure (BP) (cardiovascular). Crackles in the lungs are present with pneumonia (respiratory) and heart failure (cardiovascular). Confusion may be present with dementia (neurologic), hypoxia related to pneumonia (respiratory), or low BP (cardiovascular). Chest pain can occur with frequent coughing (respiratory causing muscular pain) or myocardial infarction (cardiovascular). Sputum production that is thick and grey is most often associated with a lower respiratory infection. Think of assessment cues like pieces to a puzzle. By themselves, the cues do not provide a clear picture of the individual's health. But when connected to other cues, things begin to become clear.

Review the picture shown here. Which area of the hand is the most missed when performing hand hygiene? 1 2 3 4

1

Look at the photo

Look at photo

Based on the MAR, Nurses' Notes, and Vital Signs tabs, what is the next thing the nurse should say to Davon? "I am concerned about giving you another shot so soon after your head injury. How about I give you some acetaminophen now and a shot in a couple of hours?" "I can give you acetaminophen now. Your next dose of meperidine can be given in 20 minutes. Would you like the pills now and the shot when it is time?" "It will be another hour before you can have something. Would you like a cup of tea or a warm blanket to help you relax?" "It is not time for the meperidine. I will come back when it is."

"I can give you acetaminophen now. Your next dose of meperidine can be given in 20 minutes. Would you like the pills now and the shot when it is time?" Rationale: Comfort is a basic human need and a high priority for the nurse. Based on the assessment data, Davon's neurological status is stable, as are her vital signs, so administering the prescribed meperidine is not contraindicated. However, it was last given at 1905 and only 2 hours and 40 minutes have gone by (the current time is 2145), making it 20 minutes too soon for another dose. Based on the cues (pain worst in arm; VS stable; neuro status stable; shot not effective for the length of time between doses; available oral pain medication), the nurse hypothesizes that the current dose of meperidine is not effectively controlling Davon's pain. Critical thinking about how the two prescribed medications work allows the nurse to realize that offering acetaminophen now will allow that medication to begin to take effect at about the same time as the next dose of meperidine can be administered. The additive effect of the two medications may allow Davon to have relief from the arm pain for the length of time between meperidine doses.

Which statement made by a client regarding use of hand sanitizer requires follow-up by the nurse? "The sanitizer needs to contain at least 60% alcohol." "I cannot use sanitizer if my hands are visibly soiled." "I need to apply the sanitizer to the front and back of my hands." "If the sanitizer doesn't dry fast enough, I can wipe it off."

"If the sanitizer doesn't dry fast enough, I can wipe it off."

A new colleague asks why the fingers should be pointed down when performing handwashing. What is the nurse's correct response? "The wrists are not covered by gloves." "They don't need to be. It is preference." "It is a reminder that the fingers should be cleaned last." "The fingers are the dirtiest part during hand hygiene."

"The fingers are the dirtiest part during hand hygiene."

The nurse (preferred pronouns: she, her) was exposed to a client with influenza two days ago. The nurse states that she feels fine, so she must not have gotten influenza. What is the best reply to this statement? "The prodromal stage is over and you are correct." "You should have had symptoms right away if you were infected." "You are in the convalescence stage and it may be months before you have symptoms." "You may still be in the incubation stage and not have symptoms yet."

"You may still be in the incubation stage and not have symptoms yet."

Two hours into the shift, the current nurse receives a call from the colleague who cared for Mr. Hilliard the previous shift. The colleague shares that they forgot to document a call to Mr. Hilliard's healthcare provider about a potential surgical wound infection and asks the current nurse to document that information. What is the best response by the current nurse? "I will leave you a few lines on the flowsheet so you can add that in when you get back tonight." "You'll be back tonight, just add it as a late entry." "Don't worry about it. The healthcare provider has been here and mentioned the call in their note, so you are covered." "Sure, just give me the details."

"You'll be back tonight, just add it as a late entry." Rationale In this situation, the best response is to remind the colleague that they should document their actions themselves when they return to work. It is not acceptable to document actions taken by others (such as notifying a healthcare provider), leave open lines in written documentation (such as on a paper flowchart), or omit documenting your actions since they were documented by another health team member. When making a late entry, record the date and time the entry was made, followed by the date and time at which the care was provided, then the information to be documented.

While assessing Mr. Stanton, the nurse links which assessment cues to his level of pain? Select all that apply. Pain score 6/10 Request for more pain medicine before next dose can be given Respirations 14 per minute at rest Heart rate 117 bpm at rest Mr. Stanton mentions having a headache Facial grimacing each time he moves the casted leg

-Facial grimacing each time he moves the casted leg -Mr. Stanton mentions having a headache -Request for more pain medicine before next dose can be given -Heart rate 117 bpm at rest -Pain score 6/10 Rationale: Indicators of pain include facial expressions (grimacing or frowning), a high value assigned to the pain scale, requesting pain medicine before the prescribed time between doses has passed, heart rate (if elevated at rest, which Mr. Stanton's is), respirations (if elevated at rest, which Mr. Stanton's are not), and blood pressure (if elevated, but was not provided for Mr. Stanton).​ Although Mr. Stanton's headache is, most likely, not related to his leg, it still relates to pain and should be assessed thoroughly as it may be a cue to a complication resulting from alcohol withdrawal or his recent surgical procedure. Remember that all assessment data needs to be critically analyzed in relation to the client's current health, even if it appears to be insignificant now. If, when asked about his headache in 30 minutes, Mr. Stanton says it is the worst pain he has ever felt, the discovery of the headache during conversation becomes more important. Most likely, it will get better, but since we don't know, it is worth asking about, documenting, and reassessing later.

Place the listed steps for creating a concept map in order from beginning to end. Place the sub-concepts. Review the concept map. Collect and analyze information. Identify connections, similarities, and cross-links. Revise the concept map as new information is discovered. Identify the main health concern on which to focus.

1.Collect and analyze information. 2.Identify the main health concern on which to focus. 3.Place sub-concepts. 4.Identify connections, similarities, and cross-links. 5.Review the concept map .6.Revise the concept map as new information is discovered.

When discussing a client's condition with the healthcare provider over the phone, the provider asks how many hours passed between the client's last normal heart rate (pulse) and the most recent result. ​ Select the correct number of hours below.​ 6.5 hours 10 hours 16 hours 4.5 hours

10 hours Rationale: 10 hours is the correct answer.​ At 2237 on 8/13, the client's pulse was 86. The most recent result was taken 8/14 at 0837. The quickest way to "count" hours between days is to add the hours before and after midnight represented by the two times.​ 2200 is 2 hours before midnight and 0800 is 8 hours after midnight. 2 + 8 = 10 hours. Note that no adjustment was needed for the minutes, as they were the same.

The nurse working the evening shift is recording a blood pressure taken at the time shown on the clock. How is the time written using the 24-hour clock?​ 8:00 p.m.​ 2000​ 8:00 a.m. 0800​

2000​ Rationale: 2000 is the correct answer. ​ To convert time on a 12-hour clock like the one shown, first determine if it is before or after noon. Since the nurse is working the evening shift, we know it is afternoon, or p.m. Next, add 12 hours to the time.

For each time written according to the 12-hour clock, write the same time using the 24-hour clock.​ Example: One minute past midnight is written 12:01 a.m. using the 12-hour clock and 0001 using the 24-hour clock. 12-Hour 1:45 a.m. ​4:59 a.m.​ 6:24 p.m.​ 6:07 a.m.​ 11:00 a.m.​ 2:00 p.m.​ 5:01 p.m. ​6:30 p.m.​ 8:33 p.m. ​11:00 p.m.​

24-Hour Clock 0145 0459 1824 0607 1100 1400 1701 1830 2033 2300

The nurse is performing surgical hand antisepsis. How long should they wash their hands for? 1 minute 20 seconds 10 minutes 4 minutes

4 minutes

The infection control nurse is creating an education session to review isolation precautions. Which organization's guidelines for infection prevention should the nurse review? Centers for Disease Control and Prevention National Foundation for Infectious Diseases Association for Professionals in Infection Control and Epidemiology Occupational Safety and Health Administration

Centers for Disease Control and Prevention

Which client care aspect of asepsis is demonstrated when items are stored in a sterile packaging prior to use? Barriers Contact guidelines Environmental controls Client and equipment preparation

Client and equipment preparation

Concept mapping encourages students to think in a less _______ fashion than the nursing process when planning ________ care. In this way, the concept map provides insight into the student's __________ and __________.

Concept mapping encourages students to think in a less linear fashion than the nursing process when planning client-focused care. In this way, the concept map provides insight into the student's critical thinking and clinical judgment.

After a year of planning and saving, Davon (preferred pronouns: she, her) and her partner are taking a well-deserved beach vacation. During their bicycle tour, one of the other sight-seers stops suddenly, causing Davon to swerve and crash. Despite wearing a helmet, Davon loses consciousness. When paramedics arrive, they ask Davon's partner about her health history. What is the best way to provide this information? Electronically by Davon's partner accessing a copy of her EHR Verbally by Davon's partner Asking Davon when she regains consciousness Electronically by the paramedics' accessing Davon's EHR with the permission of her partner

Electronically by Davon's partner accessing a copy of her EHR Rationale: The most efficient way for Davon's partner to provide her complete health history is by having access to her EHR, which is something most EHRs allow patients to provide. This is useful for families with children, adults caring for aging parents, and those who travel together. Individuals can access their EHR via a mobile app on mobile phones, tablets, and computers.​ Davon's partner may not know her complete health history or forget details in the stress caused by her accident. Waiting for a client to regain consciousness is not the best way to obtain health information as it may delay care. Even if Davon's partner gives permission for the paramedics to search their database for Davon's health information, with them being on vacation, it is unlikely they will have access to her health records since she is from out of town.​

The nurse is instructed to control the environment in a surgical setting. Which actions should the nurse take? Select all that apply. Verify instruments are sterile. Ensure that only authorized persons enter. Minimize traffic flow. Keep the doors closed. Make sure the room is clean. Maintain sterile technique.

Ensure that only authorized persons enter. Minimize traffic flow. Keep the doors closed.

Match each handwashing action to its corresponding rationale. Hand sanitizer cannot be used on soiled hands. Do not wipe excess sanitizer off. Rub sanitizer over all surfaces of the hands.

Hand sanitizer cannot be used on soiled hands.It must come in contact with skin directly to be effective.Do not wipe excess sanitizer off.Drying kills the microbes.Rub sanitizer over all surfaces of the hands.Clean the most often missed areas on the hands during handwashing. Friction is not needed to be effective.

Washing hands with regular soap and water is called

Handwashing

In which situations would the nurse appropriately use soap and water to decontaminate the hands? Select all that apply.

Has visibly soiled hands after changing the bedding of a client After exposure to a client with potentially infectious diarrhea

How have nursing students said using concept mapping to plan care has helped them? In other words, how can concept mapping help you reach your dream of being a nurse? Select all that apply. Helps you see the whole picture Encourages you to think and reason better Improves communication with your peers and instructor Takes more time than a traditional nursing care plan Promotes individual study

Helps you see the whole picture Encourages you to think and reason better Improves communication with your peers and instructor Rationale: ositive feedback about concept mapping from students included: Can see a plan of care in a whole picture Feel very interested, are motivated to think and reason out better, and have an enhanced holistic approach Can give a clear understanding of nursing diagnoses and interventions Are encouraged to critically think and believe their thinking process has changed Consider that making a nursing plan this way is less (not more) time consuming than using traditional care planning Have increased chances to share and care within the group (promote collaborative learning not individual study) Communicate more with the other students and their nursing instructor Are given an excellent way of creating a plan of client care including interpreting problems (Kusoom & Charuwanno, 2017, p. 264) Students did share that the process of mapping and identifying related items took longer to complete. But, as they improved their thinking, the time decreased.

Maria tested positive for COVID-19 and her symptoms worsened.

Illness Rationale: The illness is when the symptoms worsen and infection is at its worst.

____________ related to ____________________and perceived weakness as evidenced by_______________, fatigue, and thick, oral secretions. ​

Impaired nutrition: less than body requirements related to sores in mouth and perceived weakness as evidenced by recent weight loss, fatigue, and thick, oral secretions. Rationale: Notice that the supporting cues include both subjective and objective data.​ ​

Advantages of Electronic Health Records What are the advantages to clients that are realized by using an electronic health record (EHR)? Select all that apply. Increased safety​ Access to complete data​ Continuity of care​ Decreased liability​ Provides audit trails​ Accessible data for research​

Increased Safety Continuity of Care Rationale: Although all options represent advantages realized with an EHR, only continuity of care and increased safety directly benefit the client. ​ Healthcare providers benefit from having complete data available when assessing and treating clients whose information is stored in an EHR and the decreased liability realized by the checks and balances of an electronic documentation system.​ The availability of audit trails and accessible data for research within an electronic record directly benefits auditors and researchers responsible for collecting this data. In the long run, however, clients and health professionals benefit from audits (cost of care covered, systems improvement) and research (deeper knowledge of illness and the human response).

In what ways do nursing students benefit from the creation of concept maps when learning the nursing process? Select all that apply. Increased use of analytic skills Easier memorization of standard procedures Ability to see relationships between data not previously visible More focus on the technical aspect of care Development of critical thinking

Increased use of analytic skills Ability to see relationships between data not previously visible Development of critical thinking Rationale: Concept mapping encourages thinking "outside the box" and in a less linear fashion when compared to the nursing process. In some ways, a concept map is a visual representation of clinical reasoning and clinical judgment, both of which are reflected in actions. Because a concept map is the unique creation of the student, it allows them to see relationships between data that may not have been previously identified. Concept maps help expand the student's skills of analysis (recognizing and clustering cues, forming hypotheses, and creating a nursing diagnosis) and help develop a student's critical thinking and clinical reasoning skills on paper before caring for a client.

Today, Maria woke up feeling slightly tired but was fine otherwise.

Incubation Rationale: Incubation is the period of time between the initial entry of the disease into the host and the emergence of the first symptoms.

The nurse dons appropriate personal protective equipment for an infectious agent as shown in this picture. Which mode of transmission is the nurse protecting themselves from? Direct contact Indirect airborne (aerosol) Indirect biological Direct droplet

Indirect airborne (aerosol)

At this point, Nadine knows that Sheila's cues fall into three main groups or clusters: skin warm and cheeks red sore throat, stomachache, and headache not sleeping, sitting up in bed, and crying Nadine also knows that Sheila is counting on her to decide what to do next. Based on the cues known at this time, Nadine decides to take Sheila's temperature and discovers it is 102.3° F. The question that remains though is "Why does Sheila have a fever?" How can Nadine get more information to help her understand what is causing the fever? Select all that apply. Look at Shelia's throat. Ask Sheila when she first noticed her head was hurting. Ask Sheila if she is nauseated or having diarrhea. Use her phone to search for causes of a fever. See if Sheila has a rash on her body.

Look at Shelia's throat. Ask Sheila when she first noticed her head was hurting. Ask Sheila if she is nauseated or having diarrhea. See if Sheila has a rash on her body. Rationale: Based on her experience with her other children, Nadine decides to find out more about the areas Sheila says are hurting: her throat, head, and stomach. At this time, Nadine is trying to figure out what is causing her daughter's fever, so starting with the areas of her body that are hurting is the best place to start. Sheila is not itching or otherwise indicating she has a rash at this time. However, since many childhood illnesses with fever involve a rash, it is easy to quickly review her skin for signs of one. Although searching for causes of a fever may provide information, an understanding of Sheila's current condition is Nadine's priority right now.

Review the following client scenarios and match each with the correct type of infection. Localized Infection Systemic Infection A 19-year-old with athlete's foot evidenced by a rash between the toes A 29-year-old with human immunodeficiency virus (HIV) evidenced by fever and swollen lymph nodes A 6-year-old with a sore throat evidenced by a reddened, swollen pharynx A 74-year-old with influenza evidenced by body aches and fatigue A 42-year-old with a tooth abscess evidenced by a severe toothache A 29-year-old with malaria evidenced by fever and chills

Look at picture

Based on the information provided from Mrs. Smith's assessment and the critical thinking involved in creating an assessment-based concept map of the data, what are her priority nursing care needs at this time? Select all that apply. Arrange permanent placement in an assisted living facility Maintain safety during activities of daily living (ADLs) Increase strength and stamina Lower serum cholesterol and triglycerides Locate family with whom she can live

Maintain safety during activities of daily living (ADLs) Increase strength and stamina Rationale: Mrs. Smith's primary care needs are to assure her safety as she increases her strength and stamina. She will also need assistance from physical and occupational therapists to optimize the use of her right side to compensate for any permanent changes in the function of her left arm and leg. It is too soon to know if Mrs. Smith will be unable to go home, so making living arrangements is premature. There is not enough evidence at this time to know if her serum cholesterol and triglycerides are high. It is reasonable with her recent stroke and family history of vascular disease to believe that information would be available in the electronic health record (EHR) from the hospital.

Select the main reason that Mrs. Smith is being admitted to the extended care facility using the drop-down menu. Main Reason:

Optimize functional ability Rationale: Rehabilitation, as tertiary prevention, works to minimize disability and promote optimal functioning after an illness. Given Mrs. Smith's recent stroke and residual left-sided weakness, the focus of care will be on helping her gain strength, learn to care for herself in safe ways, and return her to a state of well-being by addressing the issues that have arisen since her stroke (weight loss, oral sores, and limited range of motion in shoulders). This main reason for seeking care will be used to support an initial problem statement/nursing diagnosis.

Patient stated

Patient stated: "I am so weak I cannot feed myself or brush my teeth. My doctor says I may never live by myself again, but I have no family that I can live with. It all seems so hopeless." Rationale: With the focus on rehabilitation potential, Mrs. Smith's feelings of hopelessness, inability to care for herself due to weakness, and concerns over where she will live may impact her outcomes physically and psychologically. Her recent weight loss, while concerning, does not directly impact her ability to successfully complete rehabilitation.

Healthcare agencies need to reduce the incidence of healthcare-associated infections (HAIs). Which nursing action directly meets this goal? Perform hand hygiene as appropriate. Attend educational sessions on infection prevention. Report all workplace injuries. Wash scrub uniforms as soon as possible once home.

Perform hand hygiene as appropriate.

Select the words or phrases within this documentation that are written factually.​ Date​ Time​ NURSING PROGRESS NOTE​ 07/04/xx 2145​ Client seeking care of burn on right handprobably sustained setting off fireworks; client states, "My hand hurts like I just gave birth to a watermelon."; individual is obviously drunk; fruity smell to breath; unable to walk a straight line; laughing inappropriately; partner and two toddlers at bedside ---------- CL Granger, RN

burn on right hand ient states, "My hand hurts like I just gave birth to a watermelon." fruity smell to breath; unable to walk a straight line; laughing inappropriately; partner and two toddlers at bedside