A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
a. "It mechanically removes biofilm on teeth."
b. "It's easier to clean all surfaces with a brush."
c. "Oral care is important to all our clients."
d. "Toothbrushes last longer than oral swabs."
ANS: A
Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.
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While assessing the client at risk for shock, a nurse finds the client's systolic blood pressure to be 20 mm Hg lower than baseline. What is the nurse's best first action?
A. Increase the IV rate. B. Administer oxygen. C. Notify the physician. D. Document the finding as the only action.
A client who sustained a crush injury to the right lower leg in a farm tractor accident complains of numbness and tingling of the affected extremity. The skin of the right leg ap-pears pale and the pedal pulse is weak
What should be the nurse's first response? A. Notify the physician. B. Loosen the dressing. C. Increase the IV flow rate. D. Document the finding as the only action.
Which of the following patients is most likely to feel closer to American culture than to his or her culture of origin?
A) A first-generation resident of the U.S. B) A person who immigrated to the U.S. as an infant C) A person who has newly immigrated to the U.S. D) None of the above
Which statement illustrates the most measurable outcome indicator?
a. Demonstrates dressing change b. Shares innermost thoughts c. Understands instructions d. Shows personal remorse