A nurse is preparing to apply personal protective equipment before caring for a client who requires isolation precautions. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) (ORDERED RESPONSE)

Put on a gown.

Don a mask.

Put on goggles.

Don gloves.

Answer and Explanation

Correct Answer : A,B,C,D

A. Put on a gown: The gown is applied first to prevent contamination of the nurse’s clothing and skin. It acts as the foundational barrier and should be secured at the neck and waist to ensure full coverage before other PPE is donned.

B. Don a mask: The mask is put on second to protect the respiratory tract from airborne or droplet contaminants. Proper placement over the nose and mouth is essential before entering the client’s room to reduce inhalation of infectious particles.

C. Put on goggles: Goggles or a face shield are worn next to shield the eyes from splashes or sprays of infectious material. Since the eyes are a mucous membrane, they must be protected after covering the mouth and nose.

D. Don gloves: Gloves are put on last and should cover the cuffs of the gown to ensure a complete barrier. This final step helps prevent the transmission of pathogens via the hands when interacting with the client or the environment.

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Correct Answer is A

Explanation

A. "I will be told about alternative procedures before I'm asked to sign the consent form." Understanding alternative options is a key component of informed consent. Clients must be informed about the risks, benefits, and alternatives to the proposed procedure so they can make a voluntary, educated decision.

B. "My nurse is responsible for obtaining informed consent." While nurses often witness the client’s signature and may provide teaching, the responsibility for obtaining informed consent legally lies with the provider performing the procedure, who must explain the details and answer questions.

C. "Once I sign the consent form, I cannot change my mind about having the procedure." Clients retain the right to withdraw consent at any time before the procedure begins. Signing the form does not waive this right, and they can refuse or delay the procedure if they choose.

D. "The consent form will include the estimated time for my recovery from the procedure." Recovery time is usually discussed during preoperative teaching but is not a required element of the consent form itself. The form primarily covers procedure details, risks, and alternatives.

A. Prick the side of the client's finger. B. Squeeze the client's finger until a blood drop forms. C. Elevate the client's hand above the level of the heart. D. Apply clean gloves. E. Cleanse the client's finger with an iodine swab.

Correct Answer is ["A","D"]

Explanation

A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.

B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.

C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.

D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.

E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for a surgical procedure. Which of the following statements by the client indicates an understanding of the informed consent process?

Correct Answer is A

Explanation

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A home health nurse is assisting in the care of a client. Exhibits Select the 4 findings that indicate an understanding of the reinforced teaching

A nurse in a long-term care facility is preparing to administer medications to a group of clients. Which of the following are acceptable client identifiers for the nurse to use? (Select all that apply.)

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?