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 B
Explanation
A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.
Correct Answer is A
Explanation
A. Case manager A case manager helps coordinate home oxygen therapy, arranges for home health services, and ensures the client has access to needed resources, such as durable medical equipment and personal assistance for ADLs.
B. Hospice care facility Hospice is appropriate for clients with a terminal illness and a life expectancy of 6 months or less. COPD is chronic but not necessarily end-stage.
C. Long-term care facility This client is not indicated for long-term institutional care but rather for home-based support.
D. Pharmacist While a pharmacist is important for medication education, they do not coordinate oxygen therapy or ADL assistance.
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