a community health nurse is reviewing primary prevention strategies for west nile virus with a group of clients in a rural health clinic which of the
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RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A community health nurse is reviewing primary prevention strategies for West Nile virus with a group of clients in a rural health clinic. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.

2. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct answer: C

Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.

3. The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?

Correct answer: A

Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.

4. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?

Correct answer: B

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.

5. A healthcare professional is preparing to administer the initial dose of ceftriaxone to a client who has endometritis. Which of the following statements by the client should cause the healthcare professional to hold the medication and consult the provider?

Correct answer: A

Rationale: A severe allergy to amoxicillin could indicate a potential cross-reactivity with ceftriaxone, so the medication should be held. Cross-reactivity between penicillins (like amoxicillin) and cephalosporins (like ceftriaxone) is a known concern due to their similar chemical structures. Choices B, C, and D do not directly contraindicate the administration of ceftriaxone for endometritis.

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