A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

Chlorine bleach

Chlorhexidine gluconate

Hydrogen peroxide

Isopropyl alcohol

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Chlorine bleach is correct. Chlorine bleach is an effective disinfectant against bloodborne pathogens. It's recommended for cleaning surfaces contaminated with blood spills because it can destroy various microorganisms, including bacteria and viruses. However, it's essential to follow proper dilution guidelines and safety precautions when using bleach.

Choice B Reason:

Chlorhexidine gluconate is incorrect. While chlorhexidine gluconate is an antiseptic commonly used for skin disinfection before medical procedures or as a surgical scrub, it's not typically used for cleaning blood spills on surfaces. Its primary application is for skin disinfection, not environmental surface cleaning.

Choice C Reason:

Hydrogen peroxide is incorrect. Hydrogen peroxide is a mild antiseptic that can disinfect wounds or clean certain surfaces. However, it might not be as effective as chlorine bleach in dealing with blood spills. It's generally used more for superficial wound cleaning rather than for disinfecting large contaminated surfaces.

Choice D Reason:

Isopropyl alcohol is incorrect. Isopropyl alcohol is a commonly used disinfectant for surfaces, but when it comes to blood spills, it might not be as effective as chlorine bleach. While it can kill some pathogens, its efficacy against certain bloodborne pathogens may be limited compared to bleach.

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Correct Answer is C

Explanation

Choice A Reason:

Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.

Choice B Reason:

Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.

Choice C Reason:

Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.

Choice D Reason:

Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.

A. "He appears anxious about the transfer." B. "He is allergic to sulfa." C. "His partner has been visiting." D. "He is voiding adequately."

Correct Answer is B

Explanation

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking for the proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

Correct Answer is C

Explanation

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?