The nurse is caring for hospitalized clients. Which nursing action requires the nurse to use sterile gloves?

Administration of an enema

Administration of an intramuscular injection

Insertion of a nasogastric tube

Insertion of an indwelling catheter

Answer and Explanation

The Correct Answer is D

D. Inserting an indwelling catheter involves placing a tube into the bladder through the urethra. The urethra and urinary tract are sterile areas. Sterile gloves are necessary to prevent introducing pathogens into the urinary tract during catheter insertion.

A. An enema involves introducing a solution into the rectum for therapeutic purposes. It does not require the use of sterile gloves because the rectum and lower gastrointestinal tract are not considered sterile areas.

B. Administering an intramuscular injection involves injecting medication into muscle tissue. It does not require sterile gloves unless the site needs to be cleaned with an antiseptic wipe, in which case non- sterile gloves are sufficient.

C. The insertion of a nasogastric tube also does not typically require sterile gloves, as the gastrointestinal tract is not a sterile environment.

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Correct Answer is B

Explanation

B. Activating a code blue or the facility's emergency response system will bring immediate assistance and resources to the client's bedside. This is crucial to initiate prompt resuscitative measures if indicated and to involve additional healthcare providers in the management of the emergency.

A. While it might be appropriate in some situations to provide privacy or support to the partner, in this urgent scenario where the client is unresponsive and not breathing, the priority should be immediate assessment and intervention for the client's condition.

C. While notifying the physician is important, especially to inform them of the client's condition and potentially discuss the DNR status, it is not the most immediate action in this urgent situation where the client is unresponsive and not breathing. Direct intervention and assessment are needed first.

D. Asking the partner to make a DNR decision immediately is not appropriate as the first action in this scenario. It is crucial to focus first on the client's immediate needs for assessment and potentially resuscitative measures if indicated. The discussion about the DNR order should occur in a timely manner but is secondary to addressing the client's current medical emergency.

A. nonmaleficence. B. justice. C. fidelity. D. autonomy.

Correct Answer is A

Explanation

A. This principle emphasizes the duty to do no harm. In the case of the client undergoing chemotherapy and experiencing severe side effects that significantly reduce their quality of life, the principle of nonmaleficence comes into question. Chemotherapy, while aimed at treating cancer, often causes substantial side effects that can impact a patient's well-being

BThis principle relates to fairness and equality in the distribution of resources, treatments, and outcomes. In the context of cancer treatment, justice could be considered in terms of ensuring equitable access to chemotherapy and supportive care, regardless of socioeconomic status or other factors.

C Fidelity refers to the duty to be faithful, keep promises, and maintain trust in the patient-nurse relationship. In this context, fidelity would involve the nurse advocating for the client's best interests, including addressing their concerns about the severe side effects of chemotherapy and their impact on quality of life.

D. Autonomy refers to respecting the right of the patient to make their own decisions about their care and treatment. In the context of cancer treatment, autonomy would involve ensuring that the client has sufficient information about their condition, prognosis, treatment options, and potential side effects to make informed decisions. However, autonomy may also be challenged when severe side effects significantly impact the client's ability to maintain their desired quality of life despite ongoing treatment.

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The nurse is caring for hospitalized clients. Which nursing action requires the nurse to use sterile gloves?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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