A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
Encouraging the client to consume a high-protein diet
Performing hand hygiene before, during, and after direct contact with the client
Placing the client in a room with positive-pressure airflow
Changing the client's bed linens each day
The Correct Answer is B
A. While a high-protein diet can support healing, it does not directly prevent the transmission of infection.
B. Performing hand hygiene before, during, and after direct contact with the client is crucial to prevent the transmission of pathogens and is a fundamental practice in infection control.
C. Positive-pressure airflow is used for clients who are immunocompromised to prevent them from contracting infections, not for clients with existing infections.
D. Changing bed linens daily can contribute to infection control but is not as effective as hand hygiene in preventing transmission.
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Correct Answer is A
Explanation
A. Determining the location of the pain is the first step, as it helps the nurse understand the nature and source of the pain, guiding appropriate intervention and medication administration.
B. Repositioning the client may provide comfort but should follow an assessment of the pain to ensure targeted interventions.
C. Administering the medication without understanding the specifics of the pain is inappropriate, as it may not adequately address the client’s needs.
D. Reviewing the effects of the pain medication is important but should occur after assessing the pain to ensure the correct medication is administered based on the client’s specific situation.
Correct Answer is A
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.