A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow?

Correct Answer: A

Rationale: The correct answer is A: Standard precautions. Standard precautions should be followed by the nurse when changing bed linen as it includes practices to prevent the transmission of infectious agents. This includes hand hygiene, the use of personal protective equipment if necessary, proper handling and disposal of linen, and environmental cleaning. Droplet, contact, and airborne precautions are specific isolation precautions used for different modes of transmission of infections. In this scenario, standard precautions are appropriate as they cover a wide range of potential risks and are recommended for all patients regardless of their infectious status.

Correct Answer: D

Rationale: The correct answer is D. In this scenario, the child has injured the right leg, indicating a localized injury. Signs of a localized inflammatory response include edema (swelling), redness, tenderness, and loss of function in the affected area. Edema and redness occur due to increased blood flow and fluid accumulation at the site of injury. Tenderness is a result of irritation of nerve endings, and loss of function can occur due to pain and swelling limiting movement. Choice A is incorrect because malaise, anorexia, enlarged lymph nodes, and increased white blood cells are more indicative of a systemic inflammatory response rather than a localized one. Choice B is incorrect as chest pain, shortness of breath, nausea, and vomiting are not typical signs of a localized inflammatory response. Choice C is incorrect as dizziness and disorientation are not specific signs of inflammation in a localized area. In summary, the signs and symptoms in choice D align with a localized inflammatory response

Correct Answer: C

Rationale: The correct answer is C: Teaching the patient to select nutritious foods. Proper nutrition supports the immune system, reducing the risk of infection. Nutritious foods provide essential vitamins and minerals necessary for immune function. Fall prevention (Choice A) is important for safety but does not directly decrease infection risk. Taking a temperature (Choice B) is a monitoring activity and not a preventive measure against infection. Teaching about alcohol effects (Choice D) is unrelated to infection prevention.

Correct Answer: B

Rationale: The correct answer is B. Allowing the drainage bag port to touch the graduated receptacle increases the risk of contamination and infection as it can introduce bacteria into the urinary system. This can lead to a UTI. Reusing the receptacle (A) can also introduce bacteria but is not as direct as touching the port. Emptying the bag frequently (C) can actually decrease the risk by preventing bacterial buildup. Irrigating the catheter infrequently (D) is not ideal but is not directly related to the risk of contracting a UTI.

Correct Answer: A

Rationale: The correct answer is A because placing used dressings in a plastic bag helps contain and prevent the spread of contaminants. This practice reduces the risk of exposure to infectious materials. Option B is incorrect as saving part of the dressing can lead to contamination. Option C is incorrect because removing gloves before gathering items may lead to potential exposure. Option D is incorrect as wrapping the dressing in toilet tissue is not a secure method of containment. Overall, option A is the best choice for proper management of contaminated dressings.