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 B

Choice A reason: Washing hands before handling the needle and syringe is a good practice, but it does not indicate an understanding of standard precautions. Standard precautions are measures to prevent the transmission of infectious agents from contact with blood, body fluids, non-intact skin, and mucous membranes. Washing hands is part of hand hygiene, which is a component of standard precautions, but not the only one.

Choice B reason: Wearing gloves to dispose of the needle and syringe is the best action to indicate an understanding of standard precautions. It protects the client from exposure to blood or body fluids that may be on the needle or syringe. It also prevents the client from accidentally injuring themselves with the sharp object.

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 D

Explanation

Choice A reason: Muscle strength and tone is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have musculoskeletal problems, but it does not indicate the risk of thermal injury.

Choice B reason: Limitations to range of motion is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have joint stiffness or pain, but it does not indicate the risk of thermal injury.

Choice C reason: Presence of rebound phenomenon is not the most important assessment for the nurse to perform prior to the application of a heating pad. It is a sign of peritoneal inflammation that occurs when pressure is released from the abdomen. It has nothing to do with the application of a heating pad.

Choice D reason: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. It indicates the client's ability to perceive heat and pain sensations. If the client has impaired neurosensory function, the nurse should avoid using a heating pad or use it with caution and frequent monitoring.

A. Remove nasal cannula. B. Increase the oxygen to 3 L/minute. C. Verify placement of pulse oximeter. D. Switch to a non-rebreather mask.

Correct Answer is C

Explanation

Choice A reason: Removing the nasal cannula is not appropriate as it would deprive the client of supplemental oxygen. The client's oxygen saturation is below the normal range of 95% to 100%, indicating hypoxemia.

Choice B reason:While increasing oxygen might seem appropriate, this should only be done after verifying the accuracy of the pulse oximeter reading and assessing the client’s overall condition. Automatically increasing oxygen without further assessment could delay addressing other underlying issues or lead to over-oxygenation in clients with certain conditions like COPD.

Choice C reason:The first step is to ensure the accuracy of the pulse oximeter reading by checking its placement and ruling out factors that can interfere with accurate readings, such as poor circulation, cold extremities, nail polish, or motion artifacts. This ensures that the subsequent intervention is based on reliable data.

Choice D reason: Switching to a non-rebreather mask is not necessary as it would deliver a high concentration of oxygen (up to 100%) that may be excessive for the client. A nasal cannula can deliver oxygen from 1 to 6 L/minute, depending on the client's needs.

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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

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is C

Explanation

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

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

The nurse is preparing to administer hydrocodone to a client admitted with urolithiasis who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?