A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?
The client has difficulty swallowing.
The client reports insomnia.
The client requires additional help to stand.
The client has increased difficulty dressing.
The Correct Answer is A
A. Difficulty swallowing (dysphagia) is the priority because it increases the risk of aspiration, which can lead to aspiration pneumonia, a serious and potentially life-threatening complication for clients with Parkinson's disease.
B. Insomnia, while impacting quality of life, is not as immediately life-threatening as aspiration risk.
C. Needing additional help to stand reflects disease progression but does not carry the immediate risk of a life-threatening complication.
D. Difficulty dressing also indicates disease progression but does not pose an immediate danger to the client’s health.
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Correct Answer is B
Explanation
A. Informing the charge nurse of the need to reassign the client’s care is unnecessary unless the nurse is unable to provide safe and competent care for the transfusion.
B. Obtaining informed consent is essential before a blood transfusion to ensure the client is aware of the procedure's purpose, benefits, and potential risks.
C. Delegating the client's care to another RN may be appropriate if the nurse lacks competence with transfusions, but obtaining consent is a priority.
D. Accessing the nursing information system for transfusion guidelines is helpful, but obtaining consent takes precedence before proceeding with the transfusion.
Correct Answer is C
Explanation
A. Placing a midstream urine sample in a specimen refrigerator is an appropriate practice and does not pose an infection control hazard.
B. Wiping a countertop with chlorhexidine solution is a correct practice following a blood spill and contributes to infection control.
C. Pouring sterile 0.9% sodium chloride irrigation solution directly onto an open pressure wound before collecting a specimen poses an infection control hazard, as it can introduce contaminants to the wound and affect the culture results.
D. Using alcohol-based antiseptic to clean hands after interacting with a client who has varicella zoster is an appropriate infection control measure and reduces the risk of spreading infection.