The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.)
"Have you traveled outside of the United States?"
"Will you demonstrate how to wash your hands?"
"Can you explain the risk for infection in your home?"
"What are the signs and symptoms of infection?"
"Are you able to walk to the mailbox?"
"Who runs errands for you?"
Correct Answer : A,B,C,D
A. Asking about travel outside the United States helps identify potential exposure to infections that are more prevalent in certain areas.
B. Assessing handwashing techniques is crucial, as proper hand hygiene is a fundamental way to prevent infections.
C. Understanding the patient's perception of infection risk in their home environment can highlight potential areas for intervention.
D. Knowing the signs and symptoms of infection allows the nurse to evaluate the patient’s awareness and ability to recognize early signs of infection.
E. While mobility can affect overall health, it is not directly related to assessing the risk of infection.
F. Knowing who runs errands may provide context for the patient's support system, but it does not directly assess infection risk.
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Correct Answer is D
Explanation
A. The Good Samaritan Law typically protects individuals who provide care in emergency situations but may not apply if the actions taken are beyond the standard of care or are not in the nurse's training.
B. While the nurse's intention was to save the patient's life, the method employed was not a recognized standard procedure for airway management and may have caused harm.
C. Waiting for help may not have been an appropriate option if the patient's airway was compromised, but the method employed by the nurse was not advisable.
D. Cutting into the trachea and using a straw as a makeshift airway are actions that exceed the typical scope of nursing practice and could be deemed inappropriate, regardless of the outcome for the patient.
Correct Answer is D
Explanation
A. An increase in heart rate does not directly affect hemoglobin levels; this option is incorrect.
B. A higher heart rate decreases diastolic filling time, as there is less time for the heart to fill between beats, which can lead to reduced stroke volume.
C. An increased heart rate does not inherently increase stroke volume; in fact, at very high rates, stroke volume can decrease due to reduced filling time.
D. The significant increase in heart rate to 164 beats/min can lead to decreased cardiac output due to compromised diastolic filling and reduced stroke volume.