A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called “the kissing disease.” The nurse explains that the organisms causing this disease were transmitted by:

Correct Answer: A

Rationale: The correct answer is A: direct contact. Mononucleosis is commonly spread through the exchange of saliva, such as kissing or sharing utensils. Direct contact allows for the transmission of the infectious organisms directly from one person to another. Indirect contact (B) involves transmission through contaminated objects, which is not the primary mode of transmission for mononucleosis. Airborne route (C) is when pathogens are spread through the air, which is not typical for mononucleosis. Vectors (D) are organisms that can transmit disease but are not involved in the transmission of mononucleosis.

Correct Answer: D

Rationale: The correct answer is D: Urinary catheterization. This procedure carries the greatest risk for a nosocomial infection due to the direct introduction of pathogens into the urinary tract. Steps in catheterization involve breaching the body's natural defense barriers, increasing susceptibility to infections. The other choices (A: Enema, B: Intramuscular injections, C: Heat lamp) do not involve invasive procedures like catheterization, which significantly elevate the risk of nosocomial infections. Enemas and intramuscular injections are typically sterile procedures, while the heat lamp does not involve direct entry into the body, thus posing a lower risk of infection compared to urinary catheterization.

Correct Answer: C

Rationale: The correct answer is C: Risk for Imbalanced Body Temperature. When a client has a serious bacterial infection, the body's response includes fever, which can lead to an imbalance in body temperature regulation. Dehydration can exacerbate this issue. Nursing diagnosis C is the most appropriate as it directly relates to the physical effects of the infection, helping the nurse anticipate and address potential complications. Choice A, High Risk for Infection, is not the best choice as the client already has a bacterial infection, so the risk is not high but rather already present. Choice B, Excess Fluid Volume, is unlikely in a dehydrated client. Choice D, Risk for Latex Allergy Response, is not related to the physical effects of the bacterial infection and dehydration.

Correct Answer: A

Rationale: The correct answer is A because using sterile gloves to handle the entire drape surface ensures the sterility of the working area during the urinary catheterization procedure. By using sterile gloves, the nurse maintains aseptic technique and prevents contamination of the sterile field. Choice B is incorrect because folding the lower edges of the drape over the sterile-gloved hands may lead to contamination of the sterile field as the gloves are not in direct contact with the drape surface. Choice C is incorrect because touching only the outer two inches of the drape when not wearing sterile gloves does not ensure complete sterility and may still lead to contamination of the working area. Choice D is incorrect because allowing clothing to touch the drape can introduce contaminants to the sterile field, compromising the aseptic technique required for the procedure.

Correct Answer: A

Rationale: Step 1: Artificial fingernails harbor bacteria and can increase the risk of infection transmission. Step 2: Direct client care involves close contact, making it crucial to minimize bacterial transmission. Step 3: Avoiding artificial fingernails helps maintain proper hand hygiene practices. Step 4: Therefore, option A is correct. Summary: Option B is incorrect because nonsterile gloves should not be decontaminated and reused between clients. Option C is incorrect as handwashing is necessary after restroom use. Option D is incorrect since sterile gloves do not eliminate the need for hand hygiene.