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: A

Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.

Correct Answer: B

Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.

Correct Answer: C

Rationale: The correct answer is C: Clinical decision support system. A clinical decision support system is a type of system or design that helps healthcare professionals, including nurses, in making clinical decisions by providing them with relevant information and knowledge. This system assists in analyzing data to generate patient-specific recommendations or alerts to improve patient care. In the given scenario, the nurse's need to find, evaluate, and use information effectively aligns with the purpose of a clinical decision support system. This system enables the nurse to access evidence-based information, guidelines, and recommendations to enhance their decision-making process and improve patient outcomes. Summary of why other choices are incorrect: A: Computer competency does not equate to informatics competency. While computer skills are important, informatics involves a deeper understanding of using information effectively in practice. B: This choice provides a detailed explanation of informatics but does not directly address the type of system or design the nurse would be using to find, evaluate, and use information effectively. D: Nursing process

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: A

Rationale: The correct answer is A: Red wine colored. Following a prostatectomy, continuous bladder irrigation is commonly used to prevent blood clots and ensure urine drainage. The output is expected to be red wine colored, indicating the presence of blood in the urine due to surgical trauma. Tea-colored (choice B) or amber (choice C) are not specific enough and do not accurately reflect the expected bloody output. Light pink (choice D) may suggest a lower level of bleeding compared to red wine color, but it is not the most accurate description for post-prostatectomy drainage.

Correct Answer: A

Rationale: The correct answer is A because acknowledging the patient's fear validates their emotions, builds trust, and shows empathy. This can help the patient feel understood and supported during a vulnerable time. Choice B is incorrect because discussing support groups may not address the patient's immediate emotional needs. Choice C is incorrect because assessing stress management skills may not be the priority at this moment when the patient is visibly tense. Choice D is incorrect because documenting a nursing diagnosis should come after addressing the patient's immediate emotional state.

Correct Answer: D

Rationale: The correct answer is D: Immunoglobulin E. The atopic response in allergies is mainly mediated by IgE antibodies. IgE binds to allergens and triggers the release of histamine and other chemicals that cause allergic symptoms. IgA is mainly found in mucosal areas, IgM is involved in early immune responses, and IgG is important for long-term immunity. IgE is specifically associated with allergic reactions due to its role in sensitizing mast cells and basophils to allergens.

Correct Answer: B

Rationale: The correct answer is B: Administer calcium gluconate. Magnesium sulfate can cause respiratory depression, leading to a low respiratory rate. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on the neuromuscular junction. Administering calcium gluconate helps reverse the respiratory depression caused by magnesium sulfate. Increasing IV fluids (Choice A) is not directly related to treating respiratory depression. Vigorously stimulating the patient (Choice C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (Choice D) may not be effective in addressing the underlying cause of respiratory depression due to magnesium sulfate toxicity.