Which age group has a limited ability to produce immunoglobulins to fight infection effectively? Infants
Which condition directly affects the immune system by increasing cortisol levels and decreasing resistance to infection?
Chronic stress
Which factor most influences the risk of developing a health care–associated infection (HAI)?
Hand hygiene practices by health care workers
Which consequence of a health care–associated infection (HAI) directly increases financial burden on patients and the health care system?
Prolonged recovery that delays return to normal function
Which action reflects the nurse’s role in preventing infection through patient-centered assessment?
Observing the patient’s hand hygiene technique after using the bathroom
Which assessment finding outlines a reason an infection may go unrecognized in older adults?
Diminished inflammatory response
Which assessment finding would require follow-up by the nurse based on age-related immune infection risks?
Older adult with a productive cough and decreased appetite Yes
Young adult female with urinary frequency and burning with urination No Urinary tract infections (UTIs) are common in young adult females
Which patient has a higher susceptibility to infection due to the effects of physiological stress?
Older adult recovering from hip surgery with elevated blood glucose
Which nursing action would significantly reduce the risk of a health care–associated infection (HAI) in an older adult with a urinary catheter and a history of recent weight loss?
Assist the patient with frequent hand hygiene and provide chlorhexidine (CHG) bathing. This action interrupts the chain of infection by addressing both the reservoir of microorganisms and the portal of entry.
Which nursing action reflects effective infection control and prevention when during discharge planning a patient states that they were not expecting to go home with an open wound?
Inviting the patient to discuss their concerns and reviewing the care plan together
Which finding would indicate that an older adult with an indwelling urinary catheter and new-onset confusion is suffering from a systemic infection?
White blood cells (WBC) count of 14,500/mm³, elevated erythrocyte sedimentation rate (ESR) and new-onset tachycardia
Which factor is important for nurses to include when caring for patients with increased safety risks?
Critical thinkingCorrect answerCritical thinking enhances a nurse’s ability to make clinical decisions about patient safety through routine application of critical thinking attitudes and intellectual standards. This is important when caring for patients who may have serious safety risks.
Sound clinical judgmentCorrect answerSound clinical judgment involves nurses applying evidence-based knowledge and standards of practice for meeting patient safety needs. This is important when caring for patients who may have serious safety risks as evidenced-based knowledge nursing may help to prevent injury for high-risk patients.
Clinical experienceCorrect answerClinical experience is invaluable to a nurse who has cared for patients with conditions that pose safety risks. Experience of seeing how conditions and interventions can impact patients, benefit nurses to engage patients to yield more information of perception, accepting, and understanding of safety issues.
Family supportFamily support is important but not necessarily essential when caring for patients with increased safety risks. Sometimes, family members do not have the ability to provide what is essential when caring for a patient with increased safety needs.
Patient environmentNurses must anticipate what environment factors pose safety risks to determine patient’s immediate impact, while also considering avoidance of environmental disruptions that can negatively impact patient care.
Which type of infection is specifically acquired during admission in a health care setting?
Nosocomial infection
Which organization focuses on annual safety standards and evaluating health care agencies for accreditation?
The Joint Commission (TJC
Which factor involves applying evidence-based knowledge and standard of practice to ensure patient safety?
Sound clinical judgment
Which safety hazard is the leading cause of poison-related deaths in the United States?
Unintentional non-fire carbon monoxide ingestion
Which times would the nurse check for the “right drug”?
During removal of the drug from the dispensing uni
While preparing the medication
Before entering the patient’s roomThe label on the medication to be administered is not checked against the MAR outside the patient’s room.
At the bedside immediately before administrationW
On completion of documentation that the medication was givenThe 7 rights of medication administration call for verification of the right drug when removing the medication from the dispensing unit, when preparing the medication, and at the bedside immediately before administration, not upon completion of documentation.
Which patient would receive the most benefit when the nurse provides a weekly medication organizer as an intervention?
Forgetful
Which comment made by a patient before discharge would alert the nurse that further teaching regarding home medication administration is required?
“I’m putting three or four of each of my pills together in a bottle for use in an emergency.”
Which details must be included in drug prescriptions to be considered legally valid?
Route, Frecuency and Date
Which term refers to the use of multiple medications, the use of potentially inappropriate or unnecessary medications, or the use of a medication that does not match a diagnosis?
Polypharmacy
Which information describes a medication history and its function in patient care?
Helps identify areas where patient education is neededCorrect answerA medication history identifies the name, dose, route of administration, time/frequency, and reason for use of all currently and recently used prescribed medications, over-the-counter (OTC) medications, supplements, and herbal or other preparations as well as information on allergies, adverse reactions, and patient compliance with the regimen. This helps to identify areas where patient education is needed.
Focuses on both current and recently used medicationsCorrect answerThe medication history asks for information about all of the medications, supplements, and substances used both currently and recently to establish a comprehensive picture.
Can guide decisions on future medications if accurate and completeCorrect answerInformation gathered in a medication history can serve as the basis for assessing the appropriateness of a patient’s current medications, prevent medication errors, guide decisions on future medications, and identify areas for patient education.
Gathers data about herbal preparations but not dietary supplementsA medication history asks the patient for information about their use of prescribed medications, OTC medications, herbal preparations, and dietary supplements.
Asks questions related to patient adherence to the prescribed medication regimenCorrect answerA medication history provides information about patient adherence with the medication plan by asking questions about why and how individual medications, supplements (including herbal preparations), and substances are used.
Which reason best supports the need for medication reconciliation as a routine part of medication error prevention?
Prevalence of polypharmacy
Which intervention by the nurse demonstrates appropriate understanding of physiology and complications affecting coordination of the musculoskeletal and nervous systems?
Implementing prevention strategiesCorrect answerWhen caring for a patient with immobility, the nurse should implement prevention strategies to reduce the risk of immobility related complications. Complications related to immobility include pressure injuries (PIs), atelectasis, pneumonia, deep vein thrombosis (DVT), and pulmonary embolisms (PEs).
Proactively addressing complicationsCorrect answerA nurse with adequate understanding of changes affecting the musculoskeletal and nervous systems will proactively address problems or complications. The nurse should regularly assess and monitor for complications and proactively intervene.
Anticipating problems related to mobilityCorrect answerBy anticipating concerns related to mobility, the nurse will be able to use critical thinking and make appropriate decisions to prevent problems. Musculoskeletal and nervous system changes place patients at risk for health-related problems.
Deferring to a physiotherapist to address mobility concernsThe nurse is required to know physiological conditions that affect body movement such as balance, alignment, posture, and activity. The physiotherapist and nurse can work together collaboratively to develop appropriate exercises and movement plans.
Consulting occupational therapy to assess a patient's fall riskThe nurse should use evidence-based information when determining a patient’s falls risk. The nurse can work in collaboration with the occupational therapist to help patients learn how to manage immobility in the home.
Which complication is associated with functional decline in older adults while hospitalized?
DeliriumCorrect answerOlder adults who are hospitalized are at risk for developing delirium and depression. The nurse should provide age-friendly environmental enhancements to support the patient such as large clocks or calendars.
Pressure injuriesCorrect answerPatients with restricted mobility and functional decline are at risk for pressure injuries while hospitalized. The nurse should assess, encourage mobility, and assess nutritional needs.
Accelerated bone lossCorrect answerOlder adults experiencing functional decline in the hospital are at risk for accelerated bone loss. Other risks include undernutrition, dehydration, and loss of independence when experiencing functional decline.
Increase basal metabolic rate (BMR)An older adult experiencing functional decline and mobility restrictions while in the hospital would also experience a decline in BMR.
Decreased cardiac workload
Which assessment finding indicates atelectasis as a result of immobility?
Hypoventilation
Which complication is a result of tissue ischemia due to immobility?
Pressure injuries (PIs)
Which physiological process is impaired when a tendon is torn?
Bone to muscle attachment
Which physical finding would the nurse recognize as a basal ganglion posture?
Stooped and hyperflexed with a narrow base
Which action would the nurse take when assessing a toddler whose parent reports the child fell while walking into the office but is uninjured?
Provide education that posture is often off balance and leads to falls
Which action by the nurse helps to reduce functional decline in hospitalized older adults?
Ensure assistive devices are in use
The nurse would anticipate a patient matching which description to be on bed rest?
High-risk pregnancy at risk for preterm birth YES
Postoperative day 2 from a surgical repair of a hip fracture NO
Which alteration related to nutritional status is associated with immobility?
The Basal Metabolic Rate (BMR)