A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Disposes of contaminated sheets in a linen bag

Wears clean gloves when performing oral hygiene

Empties the sharps container when it is full

Wears an N95 mask when bathing a client who has Clostridium difficile

Answer and Explanation

The Correct Answer is B

A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.

B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.

C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.

D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

A. Frequent swallowing B. Report of sore throat C. Dark brown blood between the teeth D. Coffee-ground appearance of emesis

Correct Answer is A

Explanation

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

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A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Vital Signs at 1000. For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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