A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Offer reassurance that she is not alone.

Explain that alternative treatment options may be helpful.

Encourage the wife to share her feelings.

Remind her that her husband may still live a long time.

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering reassurance that she is not alone is not the best action to take first. It may sound dismissive of her feelings and make her feel more isolated.

Choice B reason: Explaining that alternative treatment options may be helpful is not the best action to take first. It may give false hope or imply that the wife is not accepting the reality of her husband's condition.

Choice C reason: Encouraging the wife to share her feelings is the best action to take first. It shows empathy and respect for her emotional state. It also allows the nurse to assess her coping skills and provide appropriate support.

Choice D reason: Reminding her that her husband may still live a long time is not the best action to take first. It may contradict the medical prognosis and make the wife feel more confused and anxious.

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Correct Answer is D

Explanation

Choice A reason: Giving positive feedback to the PN and documenting the skill competency is not the appropriate action to take. The PN did not demonstrate proper sterile technique, as he touched the outside of the sterile glove package and the sterile sponges with his bare hands, contaminating them.

Choice B reason: Explaining to the PN that the sterile sponges are not needed for the procedure is not the relevant action to take. The PN may have been following the instructions of the healthcare provider, who may have requested the sponges for the procedure. The issue is not the need for the sponges, but the way the PN handled them.

Choice C reason: Reminding the PN to wash his hands before applying the sterile gloves is not the sufficient action to take. Washing the hands is an important step in maintaining infection control, but it does not correct the mistake the PN made by touching the sterile items with his bare hands.

Choice D reason: Asking the PN to remove the gloves and sponges and start over with a new set is the best action to take. It ensures that the PN follows the correct sterile technique and does not compromise the safety of the client or the procedure. It also provides an opportunity for the charge nurse to teach the PN how to avoid contamination.

A. Washes hands before handling the needle and syringe. B. Wears gloves to dispose of the needle and syringe. C. Dons a face mask before administering the medication. D. Removes the needle before discarding used syringes.

Correct Answer is B

Explanation

Choice A reason: Washing hands before handling the needle and syringe is a good practice, but it does not indicate an understanding of standard precautions. Standard precautions are measures to prevent the transmission of infectious agents from contact with blood, body fluids, non-intact skin, and mucous membranes. Washing hands is part of hand hygiene, which is a component of standard precautions, but not the only one.

Choice B reason: Wearing gloves to dispose of the needle and syringe is the best action to indicate an understanding of standard precautions. It protects the client from exposure to blood or body fluids that may be on the needle or syringe. It also prevents the client from accidentally injuring themselves with the sharp object.

Choice C reason: Donning a face mask before administering the medication is not a necessary action to indicate an understanding of standard precautions. A face mask is only required when there is a risk of droplet transmission of infectious agents, such as when caring for a client with respiratory infections. It is not needed for self-administration of medications, unless the medication is aerosolized or nebulized.

Choice D reason: Removing the needle before discarding used syringes is not a safe action to indicate an understanding of standard precautions. It increases the risk of needle-stick injuries and contamination. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

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A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

Correct Answer is D

Explanation

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct Answer is B

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?