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 C

Explanation

A. Blood pressure is 142/88 mm Hg:

While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.

B. Radial pulse volume is 3+:

A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.

C. 2+ edema of fingers and hands:

Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.

D. Capillary refill time is 2 seconds:

Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.

A. "This unit has a policy against staff harassment." B. "It is important to dress the right arm first." C. "Dressing must be a frustrating experience for you." D. "We will give you a class on dressing tomorrow." E. Monitor the client's white blood cell count.

Correct Answer is C

Explanation

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.

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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

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is C

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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