Saunders weekly questions
Which essential role does the nurse play in the health care team between multiple primary health care providers and specialists? 1.Facilitates communication between the team 2.Diagnoses the client and collaborates with the team 3.Implements independent interventions and shares their effectiveness 4.Reads the client's record, including reports and specialists' consultations
1.Facilitates communication between the team Nurses play a key role in facilitating communication between primary health care providers and specialists. The nurse is the center of collaboration for the client. It is necessary to communicate and share the client's information where and to who it is needed most. The nurse does not diagnose. Options 3 and 4 may be actions that the nurse takes, but these are not associated with the essential role the nurse plays in the health care team between multiple primary health care providers and specialists.
Which interventions are essential to perform when a central venous site is suspected of being infected? Select all that apply. 1.Prepare to administer antibiotics. 2.Notify the primary health care provider (PHCP). 3.Inform the client that blood cultures will need to be obtained. 4.Document the occurrence, the actions taken, and the client's response. 5.Continue to use the central venous catheter until another one is placed.
1.Prepare to administer antibiotics. 2.Notify the primary health care provider (PHCP). 3.Inform the client that blood cultures will need to be obtained. 4.Document the occurrence, the actions taken, and the client's response. Signs of infection at the catheter site include redness or drainage. The client will also exhibit chills, fever, and an elevated white blood cell count. If the nurse suspects infection, the PHCP is notified because of the risk for sepsis. The catheter is removed, and the client is prepared for a possible restart at a different location as prescribed. A central line may be removed by a nurse who has been trained in approved protocol to remove a central line. If requested, the catheter tip may be sent to the laboratory for culture to identify the bacteria present so that the effective antibiotic is prescribed. Intravenous (IV) antibiotics may be prescribed, and an IV site will be needed for administration. Blood cultures are also performed to determine the presence of bacteria in the blood. Antibiotics are not started until blood cultures are obtained; otherwise, the results of the cultures may not be accurate. Finally, the nurse documents the occurrence, actions taken, and the client's response. Additionally, per agency protocol, pictures of the infected catheter site may be taken and added to the documentation.
A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission? 1.The disease is transmitted by droplet nuclei. 2.Clothing and sheets should be bleached after each use to kill the TB nuclei. 3.Deep pile carpet collects TB bacteria and should be removed from the home. 4.The client should specifically maintain enteric precautions to prevent transmission.
1.The disease is transmitted by droplet nuclei. TB is spread by droplet nuclei or via the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. It is unnecessary to remove carpeting from the home. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand-washing technique.
A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1.Five blood cultures are negative. 2.Three sputum cultures are negative. 3.A blood culture and a chest x-ray are negative. 4.A sputum culture and a tuberculin skin test are negative.
2.Three sputum cultures are negative. The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of 3 sputum cultures are negative because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.
The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2.Wearing a gown and gloves 3.Wearing a gown, gloves, and a mask 4.Wearing a gown and gloves to change the bed linens, and gloves only for the bath
2.Wearing a gown and gloves Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.
The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction? 1."I need to bring a hat to wear during the trip." 2."I should wear long-sleeved tops and long pants." 3."I should not use insect repellents because it will attract the ticks." 4."I need to wear closed shoes and socks that can be pulled up over my pants."
3."I should not use insect repellents because it will attract the ticks."
The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which nursing action is most appropriate in preparing the client for the test? 1.Place the client in gown, gloves, and mask. 2.Request that the MRI technicians wear masks. 3.Place a surgical mask on the client for transport. 4.Call the radiology department to reschedule the test.
3.Place a surgical mask on the client for transport. If the client is on airborne precautions, client movement and transport should be limited if possible. If transport or movement is necessary, client dispersal of droplet nuclei can be minimized by placing a surgical mask on the client. Options 1 and 2 are not necessary. Option 4 is not appropriate. This leaves option 3, which is done to provide protection for the staff.
The home health nurse visits a client with suspected scabies. Which precaution should the nurse institute during the assessment of the client? 1.Wear gloves only. 2.Wear a mask and gloves. 3.Wear a gown and gloves. 4.Avoid touching the client's home furnishings.
3.Wear a gown and gloves. The Centers for Disease Control and Prevention recommends wearing gowns and gloves for close contact with a client infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Scabies usually is transmitted from client to client by direct skin contact. All contacts that the client has had should be treated at the same time.
An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information? 1."I should not wear my contact lenses." 2."New contact lenses should be obtained." 3."My old contact lenses should be discarded." 4."My contact lenses can be worn if they are cleaned properly."
4."My contact lenses can be worn if they are cleaned properly." If the adolescent wears contact lenses, he or she should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.
The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching? 1.Using friends to interpret is a conflict of interest 2.Family members should not be used due to confidentiality 3.The use of an interpreter decreases the risk of relaying inaccurate information 4.The use of an interpreter does not need to occur until the client requests one
4.The use of an interpreter does not need to occur until the client requests one
