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 D
Explanation
A. "Intensity of pain levels decrease as people age."
Pain perception does not necessarily decrease with age. Older adults experience pain similarly to younger individuals, but they may express it differently.
B. "The client is less likely to respond to analgesics." Older adults respond to analgesics, but they may be more sensitive to certain medications due to age-related physiological changes. Appropriate dosing and monitoring are essential.
C. "Pain is an expected finding for an older adult." Pain is not a normal part of aging. While some chronic conditions associated with aging can cause pain, it should always be assessed and treated appropriately.
D. "The client may under-report their pain intensity."
Older adults may under-report pain due to factors such as fear of being a burden, belief that pain is a normal part of aging, or concerns about medication side effects. Nurses should use appropriate pain assessment tools to evaluate and address their pain effectively.
Correct Answer is B
Explanation
A. "I can discuss client information in the hallway outside a client's room." Discussing client information in a public or semi-public area is a violation of HIPAA (Health Insurance Portability and Accountability Act).
B. "I will need permission from a client to share health information with a relative." Under HIPAA, health information cannot be shared with family members unless the client gives explicit permission.
C. "I can share a client's diagnosis with any member of the health care team." Information should only be shared with team members directly involved in the client's care. Not all healthcare workers need access to all client information.
D. "I will need written permission from the provider to allow a client to access their electronic medical record." Clients have the right to access their medical records without needing provider permission. The facility may have specific procedures, but a provider cannot block access unless there is a legal or safety concern.
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