A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield?
Suctioning a client's tracheostomy tube
Emptying an indwelling urinary catheter bag
Inserting an IV catheter for a client who has peritonitis
Changing the brief of an older adult client who has a Clostridium difficile infection
The Correct Answer is A
A. Suctioning a client's tracheostomy tube A face shield or goggles with a mask should be worn when performing procedures that generate aerosols or splashes, such as suctioning a tracheostomy. This helps protect the nurse from exposure to respiratory secretions.
B. Emptying an indwelling urinary catheter bag This task carries a low risk of splashing, so gloves are typically sufficient. If splashing is anticipated, wearing a gown and goggles may be appropriate.
C. Inserting an IV catheter for a client who has peritonitis IV insertion does not pose a high risk of splashes or sprays, so standard precautions (gloves) are usually adequate.
D. Changing the brief of an older adult client who has a Clostridium difficile infection While contact precautions (gown and gloves) are required for C. difficile, a face shield is not necessary unless significant splashing of fecal matter is expected. Hand hygiene with soap and water (not alcohol-based hand sanitizer) is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.
Correct Answer is B
Explanation
A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.
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