A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select the one that does not apply.)

Correct Answer: A

Rationale: The correct answer is A because a client who is ambulatory following a cardiac catheterization is not at risk for developing pressure ulcers. Pressure ulcers are caused by sustained pressure on the skin, leading to tissue damage. Clients who are immobile, have poor circulation, or poor nutrition are at higher risk. Explanation for incorrect choices: B: A client with hyperglycemia may have impaired wound healing but is not directly at risk for pressure ulcers. C: Protein-calorie malnutrition can lead to impaired tissue healing and increase the risk of pressure ulcers. D: Right-sided heart failure and edema increase pressure on the skin, leading to an increased risk of pressure ulcers.

Correct Answer: C

Rationale: The correct answer is C: Sterile cotton-tipped applicator. The nurse will use this equipment to assess the length of a sinus tract by gently inserting the applicator into the tract until resistance is felt, then marking the length on the applicator. Sterile gloves and lubricant (A) are used for wound care but not specifically for measuring the length of a sinus tract. Sterile tape measure (B) is not suitable for measuring inside a tract. Sterile irrigation tray with syringe (D) is used for wound irrigation, not for measuring the length of a sinus tract.

Correct Answer: D

Rationale: The correct answer is D: Performing hand hygiene. Hand hygiene is the most effective way to prevent the spread of infection in a healthcare setting. By washing hands thoroughly and regularly, healthcare workers can reduce the transmission of pathogens between patients and themselves. This is crucial in preventing healthcare-associated infections. Raising the temperature in each client's room (Choice A) is not an effective method for preventing infection transmission. Assessing vital signs once daily (Choice B) is important for monitoring patient health but is not directly related to preventing infection. Wearing a mask for client care (Choice C) is important in certain situations, but hand hygiene is a more universal and crucial practice for infection prevention. In summary, performing hand hygiene is the priority teaching point as it is the most effective and fundamental measure in preventing infection transmission in a healthcare setting.

Correct Answer: C

Rationale: The correct answer is C: healthcare-associated infection. This term is used to describe infections acquired while receiving healthcare in a facility, encompassing hospitals and nursing homes. It is a broader term that includes infections acquired in any healthcare setting, not just hospitals. A: Etiologic infection refers to the cause of a disease, not specifically related to healthcare settings. B: Latent infection refers to an infection where the causative agent is present but not causing symptoms at the moment. D: Hospital-associated infection is more specific to infections acquired within a hospital setting, excluding infections acquired in other healthcare facilities.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates understanding of the importance of monitoring for signs of infection after cellulitis. Fever, chills, malaise, redness, or tenderness at the site are all indicative of infection worsening. This client statement shows awareness of the need for ongoing vigilance. Choice B is incorrect because stopping antibiotics prematurely can lead to antibiotic resistance and recurrence of infection. Choice C is incorrect because squeezing pustules can introduce further infection or worsen the condition. Choice D is incorrect because drainage from the site may indicate ongoing infection and should be monitored closely.