A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Providing a newborn's first bath

Giving personal care to an infant who is HIV-positive

Suctioning secretions from a child's newly placed tracheostomy tube

Withdrawing cord blood from a neonate

Transporting a cerebrospinal fluid specimen to the laboratory

Answer and Explanation

The Correct Answer is C

Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.

Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.

Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.

Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.

Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.

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Correct Answer is A

Explanation

Choice A reason: When a patient has an elevated temperature, the body is attempting to cool down through vasodilation, which is why the skin may appear flushed and feel warm. Removing excess blankets can help facilitate the body's natural cooling process. Offering fluids is also crucial as fever can lead to dehydration, especially if there is sweating. Adequate hydration helps regulate body temperature and replaces fluids lost through sweating. The normal body temperature range is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). When the body temperature rises above this range, interventions such as removing blankets and providing fluids can be effective in reducing fever.

Choice B reason: Increasing the patient's activity is not advisable when they have an elevated temperature and are experiencing severe fatigue. Activity generates heat and can raise body temperature further, exacerbating the fever. Rest is recommended to conserve energy and reduce metabolic demand, which can help lower the body temperature.

Choice C reason: The use of ice bags can be a rapid cooling measure but must be used with caution. Direct application of ice to the skin can cause vasoconstriction and shivering, which can actually increase the body's core temperature. It is generally reserved for hyperthermia or heatstroke when immediate cooling is necessary. For a simple fever, less aggressive cooling measures are usually preferred.

Choice D reason: Decreasing the patient's intake is not appropriate unless there is a specific contraindication, such as vomiting or risk of aspiration. Adequate nutrition supports the immune system and provides the energy needed for the body to combat the underlying cause of the fever.

A. Inspect B. Percuss C. Palpate D. Auscultate

Correct Answer is D

Explanation

Choice A reason: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.

Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.

Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.

Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.

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A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:

Correct Answer is A

Explanation

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

Correct Answer is D

Explanation

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