A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Following a blood spill. I should use a bleach solution with a ratio of 1 to 20."

"Soiled dressings should be placed in a biohazard trash receptacle."

"For a client who has Clostridium difficile. I will cleanse my hands with an alcohol-based rub."

"Droplet precautions require that I wear a gown and gloves when providing client care."

Answer and Explanation

The Correct Answer is B

Soiled dressings, which may contain infectious materials, should be disposed of in a biohazardous waste container to prevent the spread of infection.

According to standard precautions, a 1:10 bleach solution (1 part bleach to 10 parts water) is recommended for cleaning up blood spills.

Alcohol-based hand rubs are not effective against Clostridium difficile. Handwashing with soap and water is necessary to remove the spores.

Droplet precautions typically require wearing a surgical mask, not a gown and gloves. Gowns and gloves are used in contact precautions.

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Correct Answer is A

Explanation

An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.

The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.

However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.

A. Evaluate the need for the client to remain in mitten restraints. B. Assist the client with range-of-motion exercises of the hands. C. Instruct the client's family about the purpose of mitten restraints. D. Determine the circulation status of the affected extremities every 2 hr

Correct Answer is B

Explanation

Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.

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A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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