The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.)

Correct Answer: D

Rationale: The correct answer is D because laying the glove package on a clean flat surface above the waistline helps maintain sterility. Placing the package above waistline prevents contamination from any potential contact with the clothing. This step ensures that the gloves remain sterile and ready for use during the catheter insertion procedure. Explanation for why the other choices are incorrect: A: While putting on the first glove, touching only the outside surface of the glove is correct, but this step alone does not address maintaining sterility during the open gloving process. B: Slipping fingers underneath the second glove cuff with the gloved dominant hand is incorrect in the context of open gloving as it introduces the risk of contamination. C: Removing the outer glove package by tearing the package open is not recommended for open gloving as it can compromise the sterility of the gloves.

Correct Answer: A

Rationale: The correct answer is A: direct contact. Mononucleosis is commonly spread through the exchange of saliva, such as kissing or sharing utensils. Direct contact allows for the transmission of the infectious organisms directly from one person to another. Indirect contact (B) involves transmission through contaminated objects, which is not the primary mode of transmission for mononucleosis. Airborne route (C) is when pathogens are spread through the air, which is not typical for mononucleosis. Vectors (D) are organisms that can transmit disease but are not involved in the transmission of mononucleosis.

Correct Answer: C

Rationale: The correct answer is C: Immune response. The immune system is the body's defense mechanism against infections. It recognizes and fights off pathogens like bacteria, viruses, and other harmful substances. The immune response involves various cells and proteins working together to neutralize and eliminate the invading pathogens. Racial characteristics (A) and body shape and size (B) are not directly related to the body's defense against infections. Level of susceptibility (D) may influence an individual's likelihood of getting infected but does not represent an active defense mechanism like the immune response does.

Correct Answer: D

Rationale: The correct answer is D: Urinary catheterization. This procedure carries the greatest risk for a nosocomial infection due to the direct introduction of pathogens into the urinary tract. Steps in catheterization involve breaching the body's natural defense barriers, increasing susceptibility to infections. The other choices (A: Enema, B: Intramuscular injections, C: Heat lamp) do not involve invasive procedures like catheterization, which significantly elevate the risk of nosocomial infections. Enemas and intramuscular injections are typically sterile procedures, while the heat lamp does not involve direct entry into the body, thus posing a lower risk of infection compared to urinary catheterization.

Correct Answer: C

Rationale: The correct answer is C: Risk for Imbalanced Body Temperature. When a client has a serious bacterial infection, the body's response includes fever, which can lead to an imbalance in body temperature regulation. Dehydration can exacerbate this issue. Nursing diagnosis C is the most appropriate as it directly relates to the physical effects of the infection, helping the nurse anticipate and address potential complications. Choice A, High Risk for Infection, is not the best choice as the client already has a bacterial infection, so the risk is not high but rather already present. Choice B, Excess Fluid Volume, is unlikely in a dehydrated client. Choice D, Risk for Latex Allergy Response, is not related to the physical effects of the bacterial infection and dehydration.