During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement?

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Spongy underlying tissue indicates possible pressure damage, not inflammation (A). 2. Excessive fluid retention is unrelated to spongy tissue and requires medical evaluation, not just notification (B). 3. Reassurance without proper assessment and intervention is inadequate and potentially harmful (C). 4. Identifying the areas as sites of pressure damage is crucial for implementing appropriate interventions and preventing further harm.

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.

Correct Answer: B

Rationale: Correct Answer: B - Recommending removing contacts at night Rationale: 1. Bacterial conjunctivitis can be exacerbated by wearing contact lenses, so it is important to avoid wearing them. 2. A - Recommending dark sunglasses can help protect the eyes from light sensitivity and reduce discomfort. 3. C - Contacting the client's school nurse can help prevent the spread of infection in a communal setting. 4. D - Performing careful hand hygiene is crucial to prevent the spread of the infection to others.