A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Place the client in a room with negative airflow.

Wear a gown when providing care to the client.

Ensure the client's room has HEPA filtration.

Wear a mask when providing care to the client.

Answer and Explanation

The Correct Answer is D

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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Correct Answer is B

Explanation

A. Asking "Would it help to discuss your feelings about this hospitalization?" is more closed and may not effectively promote discussion about the client's health history.

B. Asking "What brought you to the hospital?" is an open-ended question that allows the client to provide a comprehensive answer and facilitates a meaningful discussion about their health and hospitalization.

C. "Would you tell me about all of your medical issues?" is too broad and could overwhelm the client. A more specific question would be more effective.

D. "Do you want to talk about your health concerns?" is a yes/no question and may not encourage open communication.

A. Wears sterile gloves when moving sterile items on the sterile field. B. Positions the wrapped package on the bedside table so the outer flap is away from her. C. Holds gauze packages 15 cm (6 in) above the sterile field. D. Holds a bottle of solution with the label away from the palm of the hand.

Correct Answer is C

Explanation

A. Wearing sterile gloves when moving sterile items is appropriate practice and should not be intervened with.

B. Positioning the wrapped package so the outer flap is away from the nurse is correct to prevent contamination when opening.

C. The nurse should avoid holding sterile items too far above the sterile field to prevent contamination from falling or being exposed to non-sterile areas. Items should be held as close as possible to the sterile field, typically no more than 2 inches (5 cm).

D. Holding the bottle of solution with the label away from the palm of the hand is proper to maintain sterility.

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A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

Correct Answer is B

Explanation

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Correct Answer is C

Explanation

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