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","C","E"]

Explanation

B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.

C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.

E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.

A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.

D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.

A. enhance abilities to give quality care. B. encourage participation of clients in nursing research. C. analyze phenomena of importance to nursing. D. consider options for nursing actions.

Correct Answer is A

Explanation

A. By critically thinking about client care, nurses can assess situations, analyze data, evaluate options, and make informed decisions that contribute to the delivery of high-quality care. Critical thinking helps nurses identify priorities, anticipate potential complications, and adapt care plans based on individual client needs and responses.

B. While critical thinking is important in research and evidence-based practice, its primary role in client care is to ensure that nursing interventions are well-reasoned, evidence-based, and tailored to meet the specific needs of clients. While clients may benefit indirectly from evidence-based care resulting from nursing research, client care primarily focuses on immediate clinical decision-making and management.

C. Critical thinking involves analyzing various aspects of client care, including physiological, psychological, and social phenomena. By critically analyzing these phenomena, nurses can understand underlying issues, identify contributing factors to health conditions, and determine appropriate nursing interventions to promote health and well-being. This process helps nurses make sense of complex client situations and provide holistic care.

D. Critical thinking enables nurses to consider multiple options or strategies for nursing actions. By critically evaluating these options based on client assessment data, evidence-based practice guidelines, and ethical principles, nurses can make informed decisions about the most effective and appropriate interventions for their clients. This ensures that nursing care is individualized and responsive to the unique needs and preferences of each client.

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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

Medicare and The Joint Commission have identified which criteria that nurses must consider when using patient restraints? (SELECT ALL THAT PPLY)

Correct Answer is ["B","C","E"]

Explanation

what is the primary reason for a nurse to critically think about client care?

Correct Answer is A

Explanation

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