The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Washes hands before handling the needle and syringe.

Wears gloves to dispose of the needle and syringe.

Dons a face mask before administering the medication.

Removes the needle before discarding used syringes.

Answer and Explanation

The Correct Answer is A

Choice A reason: Hand hygiene is the foundation of Standard Precautions and the single most effective action to prevent transmission of infectious agents. Performing handwashing or using an alcohol‑based hand rub immediately before preparing or administering an injection removes transient microorganisms acquired from touching surfaces and protects both the client and the environment from contamination

Choice B reason: While wearing gloves during handling and disposal of contaminated sharps is recommended whenever there is potential contact with blood or body fluids, it is a secondary barrier. Reliance on gloves alone is insufficient because gloves can have micro‑perforations and are removed after use, making hand hygiene before and after glove use the priority

Choice C reason: Donning a face mask before administering the medication is not a necessary action to indicate an understanding of standard precautions. A face mask is only required when there is a risk of droplet transmission of infectious agents, such as when caring for a client with respiratory infections. It is not needed for self-administration of medications, unless the medication is aerosolized or nebulized.

Choice D reason: Removing the needle before discarding used syringes is not a safe action to indicate an understanding of standard precautions. It increases the risk of needle-stick injuries and contamination. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

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Correct Answer is A

Explanation

Choice A reason: This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.

Choice B reason: This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

A. Abdominal girth. B. Breath sounds. C. Bowel sounds. D. Vital signs.

Correct Answer is D

Explanation

Choice A reason: This is not the most important assessment because abdominal girth is not a reliable indicator of fecal impaction. Abdominal girth can vary depending on the client's body type, fluid status, and other factors.

Choice B reason: This is also not the most important assessment because breath sounds are not directly related to fecal impaction. Breath sounds can be affected by respiratory conditions, smoking, allergies, and other factors.

Choice C reason: This is another incorrect choice because bowel sounds are not the most important assessment either. Bowel sounds can be diminished or absent in clients with fecal impaction, but they can also be altered by other gastrointestinal disorders, medications, and dietary factors.

Choice D reason: This is the correct choice because vital signs are the most important assessment prior to initiating digital removal of a fecal impaction. Vital signs can indicate the client's hemodynamic status, pain level, and risk of complications such as vagal stimulation, perforation, or infection. The nurse should monitor the client's blood pressure, pulse, respirations, and temperature before, during, and after the procedure.

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The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Correct Answer is A

Explanation

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is D

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

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A client who had surgery 3 days ago is sitting with the head of the bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

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While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

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