A nurse is providing care to a patient with anindwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?

Correct Answer: A

Rationale: The correct answer is A: Drapes the urinary drainage tubing with no dependent loops. This practice helps prevent CAUTI by ensuring that urine does not flow back into the bladder, reducing the risk of infection. Dependent loops can lead to stagnant urine, providing a breeding ground for bacteria. Choice B is incorrect because washing the drainage tube towards the meatus can introduce bacteria into the urinary tract, increasing the risk of infection. Choice C is incorrect because placing the drainage bag on the floor can introduce contaminants from the floor into the system. Choice D is incorrect because allowing the spigot to touch the receptacle can lead to contamination and increase the risk of infection.

Correct Answer: B

Rationale: The correct answer is B: Educational programs that focus on control and prevention. This intervention is the most crucial as it directly addresses the issue of the increasing incidence of HIV infection. By providing education on how to control and prevent the spread of HIV, the nurse can empower the community to take proactive measures to reduce transmission rates. A: Lifestyle actions that improve immune function may be helpful in general health promotion but do not directly target the prevention of HIV transmission. C: Appropriate use of standard precautions is important but is more focused on healthcare settings rather than community-wide prevention efforts. D: Screening programs for youth and young adults are valuable but may not be as effective as educational programs in preventing the spread of HIV.

Correct Answer: A

Rationale: The correct answer is A because the postpartum patient who has had four saturated pads during the last 12 hours should receive further assessment. This indicates excessive postpartum bleeding (postpartum hemorrhage), which is a critical complication that requires immediate intervention to prevent complications like hypovolemic shock. Monitoring vital signs, assessing for signs of shock, evaluating uterine tone, and determining the cause of bleeding are crucial steps in managing postpartum hemorrhage. Choices B, C, and D are not the correct answers because: B: A patient with Class II heart disease complaining of frequent coughing is more likely experiencing cardiac-related issues and requires evaluation and management by a cardiologist. C: A patient with gestational diabetes and a fasting blood sugar level of 100 mg/dL is within the normal range and does not require immediate further assessment. D: A postcesarean patient with active herpes lesions on the labia requires appropriate management of the herpes infection but does not necess

Correct Answer: C

Rationale: The correct answer is C: Clear fluid from vagina. In threatened abortion, there is vaginal bleeding but the cervix is closed, indicating the possibility of the pregnancy continuing. If clear fluid is present, it suggests rupture of the amniotic sac, leading to inevitable abortion. Backache (A) and pelvic pressure (D) can be common symptoms in both threatened and inevitable abortion. A rise in hCG level (B) alone does not indicate a change from threatened to inevitable abortion.

Correct Answer: B

Rationale: The correct answer is B: Report to the emergency department or employee health department. 1. Immediate action is crucial after exposure to HIV-positive blood. 2. Reporting to the emergency department or employee health department ensures prompt evaluation and appropriate management. 3. The supervisor should also be informed to initiate the necessary protocols. 4. The other choices are incorrect: - A: Chlorhexidine may not be sufficient for post-exposure prophylaxis. - C: Hydrocolloid dressing is not appropriate for managing needlestick injuries. - D: Following up with the primary care provider may cause delays in receiving timely post-exposure prophylaxis.

Correct Answer: A

Rationale: Step 1: In Campinha-Bacote's model, the first component is "cultural awareness," which involves an in-depth self-examination of one's own background. Step 2: This self-examination helps nurses recognize their biases and assumptions, enabling them to provide culturally competent care. Step 3: By understanding their own culture, nurses can better understand and respect the cultural beliefs and practices of their patients. Step 4: This component is crucial for building trust and rapport with patients from diverse backgrounds. Step 5: Choices B, C, and D do not directly align with the cultural awareness component of Campinha-Bacote's model. B focuses on assessment, C on understanding diverse groups, and D on motivation, but they do not address the foundational self-examination required for cultural competency.

Correct Answer: C

Rationale: The correct answer is C: Women over age 40. Annual clinical breast examinations are recommended for this population group because they have an increased risk of developing breast cancer compared to younger age groups. Regular screenings starting at age 40 can help in early detection and improve survival rates. A: Women over age 21 - This age group is generally recommended to start clinical breast examinations every 1-3 years, not necessarily annually. B: Women over age 25 - While it's important to be vigilant about breast health, the risk of breast cancer increases with age, making annual exams more crucial for older women. D: All post-pubescent females with a family history of breast cancer - While family history is a risk factor, the recommendation for annual clinical breast examinations typically begins at age 40, regardless of family history.

Correct Answer: D

Rationale: The correct answer is D: "I need to call the doctor if I see flashing lights." This is because seeing flashing lights after cataract extraction with intraocular lens implant can be a sign of a serious complication like retinal detachment. Prompt reporting is crucial to prevent vision loss. Choice A is incorrect because nausea is not typically a sign of a complication related to cataract surgery. Choice B is also incorrect as a light morning discharge is normal post-surgery unless it's excessive or associated with pain or visual changes. Choice C is incorrect as a scratchy feeling is common after surgery and usually resolves on its own.

Correct Answer: A

Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.