A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Instilling an ophthalmic ointment for a client who has a corneal abrasion

Inserting an NG tube for a client who needs continuous enteral feedings

Changing a central venous catheter dressing for a client who is receiving IV therapy

Administering an IM injection to a client who has bacterial pneumonia

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Changing a central venous catheter dressing for a client who is receiving IV therapy. Choice A rationale: Instilling ophthalmic ointment typically does not require sterile gloves. Clean technique is sufficient as long as proper hand hygiene is performed to prevent infection. Choice B rationale: Inserting an NG tube requires clean technique, not sterile. The procedure is performed through the nasal passage and esophagus, which are not sterile environments. Choice C rationale: Changing a central venous catheter dressing requires sterile gloves to prevent introducing infection into the bloodstream. Central lines are a direct pathway to the central circulation, making aseptic technique critical to prevent serious infections such as bloodstream infections. Choice D rationale: Administering an IM injection requires clean technique. The skin is cleaned with an antiseptic wipe before the injection, but sterile gloves are not necessary for this procedure.

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Correct Answer is C

Explanation

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.

A. "Why do you feel the staff is the FBI?" B. "What makes you think the staff is following you?" C. "This must be very frightening for you. Let's talk more about it." D. "The psychiatric staff is not FBI. They are here to help you."

Correct Answer is C

Explanation

The correct answer is C. Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniquesto empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in the client'sreality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.

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A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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