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 B

Explanation

Choice A reason:

At the hip region is incorrect because it does not specify any clinical manifestation indicative of scoliosis.

Choice B reason

Uneven shoulder and pelvic heights are the correct position. Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often causing the spine to appear as an "S" or "C" shape when viewed from the back. When performing scoliosis screenings, the school nurse should look for signs that may indicate scoliosis, such as uneven shoulder and pelvic heights.

Choice C reason:

United tinge of moben of the hips is incorrect because it does not describe a known clinical manifestation of scoliosis and appears to contain typographical errors.

Choice D reason:

Exaggerated curvature of the sacrum is incorrect because it is not a characteristic clinical manifestation of scoliosis. The curvature of the sacrum is normal and not related to scoliosis.

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A. Instruct the client to lie supine with his knees flexed. B. Position the client in semi-Fowler's position. C. Cover the wound with a dry sterile dressing. D. Cover the wound with a transparent dressing.

Correct Answer is A

Explanation

The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.

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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 school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

Correct Answer is B

Explanation

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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