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 her hands?

Interlock her fingers and hold her hands away from her body above her waist.

Clasp her hands together in a relaxed position behind her body at her waist.

Place one hand over the other against the part of the gown covering her upper body.

Keep her arms at the sides of her body with her hands in a relaxed position.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Interlock her fingers and hold her hands away from her body above her waist.

This is because this position minimizes the risk of contaminating the sterile gloves by touching any non-sterile surfaces or objects.

The nurse should also keep her hands above her waistline to prevent contamination

Choice B is wrong because clasping the hands together behind the body at the waist could contaminate the gloves by touching the non-sterile gown or the skin

Choice C is wrong because placing one hand over the other against the part of the gown covering the upper body could contaminate the gloves by touching the non-sterile gown or the skin

Choice D is wrong because keeping the arms at the sides of the body with the hands in a relaxed position could contaminate the gloves by touching any nonsterile surfaces or objects

Sterile gloves are a type of disposable rubber gloves that are put through specific procedures to eliminate germs and microorganisms.

They are used to prevent and minimize infection during surgeries or invasive procedures

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Correct Answer is D

Explanation

The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.

The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.

The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.

Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.

Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.

Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.

Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).

Higher pressures may damage the wound tissue and increase the risk of infection.

Lower pressures may not be effective in removing debris and bacteria from the wound.

A. Use a communication board to interact with the client. B. Ask an assistive personnel who speaks the same language as the client to interpret. C. Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client’s pain level. D. Use the FACES pain scale to gauge the client’s level of pain.

Correct Answer is A

Explanation

The correct answer is choice A. Use a communication board to interact with the client.

A communication board is a tool that allows the client to point to words, pictures, or symbols that express their needs, feelings, or pain level.

This is an effective way to communicate with a client who speaks a different language than the nurse and is unable to verbalize their pain.

Choice B is wrong because an assistive personnel who speaks the same language as the client is not a qualified interpreter and may not be able to convey the client’s pain accurately or maintain confidentiality.

Choice C is wrong because the FLACC scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.

It is not appropriate for a client who is 6 hours postoperative and can communicate their pain using a communication board.

Choice D is wrong because the FACES pain scale is a self-report measure of pain intensity developed for children.

It uses facial expressions to rate the severity of pain in children from 0-103.

It is not suitable for a client who speaks a different language than the nurse and may not understand the meaning of the faces.

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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 her hands?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the nurse take to determine the client’s level of pain?

Correct Answer is A

Explanation

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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 her hands?