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 C

Explanation

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.

A. Elevate the client’s feet with two pillows. B. Raise the head of the client’s bed to a 30° angle. C. Raise the head of the client’s bed to a 60° angle. D. Place a pillow under the client’s flexed leg.

Correct Answer is D

Explanation

The correct answer is choice D. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.

It is used for vaginal and colonic examinations and natural childbirth.

Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.

The left arm should be behind the back.

Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.

The lower leg should be straightened and the upper leg should be bent.

Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.

The bed should be flat or slightly tilted.

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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

A nurse is coordinating the care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse not assign to the AP?

Correct Answer is C

Explanation

A nurse is planning to place a client into the Sims’ position. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform 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 group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.).

A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration?

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

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 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?