The nurse is teaching a client about 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 needle before discarding used syringes.

Answer and Explanation

The Correct Answer is A

A. Washes hands before handling the needle and syringe:

This action demonstrates an understanding of standard precautions. Hand hygiene, including washing hands before and after handling needles and syringes, is a fundamental component of standard precautions.

B. Wears gloves to dispose of the needle and syringe:

While wearing gloves is important for protecting oneself from potential exposure to bloodborne pathogens, it is part of personal protective equipment (PPE) precautions rather than standard precautions. Standard precautions primarily focus on hand hygiene and barrier precautions such as gloves, gowns, and masks when appropriate.

C. Dons a face mask before administering the medication:

Wearing a face mask is not typically necessary for routine administration of medications, unless there is a risk of splashes or sprays of blood or body fluids. While it's important to protect mucous membranes from exposure to potentially infectious materials, the routine use of a face mask for medication administration is not a component of standard precautions.

D. Removes needle before discarding used syringes:

This action is unsafe and does not demonstrate an understanding of standard precautions. Removing the needle before discarding the syringe increases the risk of needlestick injuries. Proper needle disposal involves keeping the needle intact with the syringe and disposing of them together in a puncture-resistant container.

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Correct Answer is B

Explanation

A. Begin the collection the next day:

This option would delay the start of the 24-hour urine collection unnecessarily. Since the client has already begun voiding, it's appropriate to start the collection process with the next void.

B. Start collecting the specimen with the next void:

Since the client has already provided a urine sample, the nurse should discard this initial void and begin the 24-hour collection process with the next void. This ensures that the entire 24-hour period is captured for accurate measurement of creatinine clearance.

C. Observe the sample for sediment:

While observing the sample for sediment may be part of the assessment process, it is not the priority in this situation. The focus should be on initiating the 24-hour urine collection process correctly.

D. Empty the sample into the 24-hour container:

The initial void should not be emptied into the 24-hour container, as this would inaccurately include urine that was not collected over the entire 24-hour period. It's important to start the collection process fresh with the next void to ensure accurate results for creatinine clearance measurement.

A. Elevate the head of the bed to a 45 degree angle. B. Lift and lock the side rails in place. C. Apply the client's positive airway pressure device. D. Remove dentures or other oral appliance.

Correct Answer is C

Explanation

A. Elevate the head of the bed to a 45-degree angle:

Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

B. Lift and lock the side rails in place:

Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.

C. Apply the client's positive airway pressure device:

This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

D. Remove dentures or other oral appliance:

While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

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

Nursing Test Bank

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