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. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.

A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.

C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.

D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.

A. Exercises to strengthen flexor muscles B. Frequent position changes to reverse the contractures C. Range-of-motion exercises to prevent worsening of contractures D. Weight-bearing activities to stimulate joint relaxation

Correct Answer is C

Explanation

C. Range-of-motion (ROM) exercises are essential in preventing contractures. These exercises aim to maintain or improve joint mobility by moving each joint through its full range of movement. They help stretch tight muscles and maintain flexibility, thereby preventing the progression of contractures.

A. While muscle strengthening exercises are beneficial for overall muscle health, in the context of contractures, the primary issue is the shortened and tight muscles. Strengthening exercises alone may not effectively address the contractures and could potentially exacerbate them.

B. Frequent repositioning is crucial to prevent and potentially reverse contractures. By changing the client's position regularly, pressure and stress on specific muscle groups are relieved, which can help prevent further tightening and promote flexibility. This intervention helps maintain joint mobility and prevents contractures from worsening.

D. Weight-bearing activities can be beneficial for joint health and bone density but may not directly address contractures. Contractures involve structural changes in the muscle-tendon unit rather than joint stiffness alone.

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

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Correct Answer is C

Explanation

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