The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC)
What action by the nurse best protects against the development of a central line–associated bloodstream infection (CLABSI)? a. Documentation of insertion date
b. Elevation of the head of the bed
c. Assessment for weaning readiness
d. Appropriate sedation management
A
Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.
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A female client returned to the clinic with a yellow vaginal discharge after being treated for Chlamydia infection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection?
a. "I did practice abstinence while taking the medication." b. "I took doxycycline two times a day for a week." c. "I never told my boyfriend about the infection." d. "I did drink wine when taking the medication for Chlamydia."
Which action should the nurse take to avoid becoming involved in a legal suit with client care?
1. Consistently follow the physician's orders. 2. Document carefully all nursing care provided. 3. Avoid using emails and fax machines to send client information. 4. Always provide friendly and respectful care to the client and families.
The nurse observes crusty brown lesions covering a client's back. To assist in identifying a possible cause, the most helpful question the nurse would ask the client is
a. "Have you recently changed laundry detergents?" b. "How much does the rash itch?" c. "What did the rash look like when you first noticed it?" d. "What did you eat last night?"
Which of these factors is the MOST common cause of altered wound healing?
a. advanced age c. hemorrhage b. smoking d. infection