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 D

Explanation

A. Criminal assault and battery:

Criminal assault and battery involve intentionally causing harm to another person without their consent. In this scenario, the nurse's actions were aimed at providing aid and ensuring the victim's safety. There is no indication of any intentional harm or violence toward the victim.

B. Negligent acts of omission:

Negligent acts of omission occur when a healthcare provider fails to act in a manner consistent with the standard of care, resulting in harm to another person. In this scenario, the nurse took certain actions to assist the victim, such as turning off the engine key and assessing the victim's condition. There is no indication of negligent omission as the nurse took appropriate actions given the circumstances.

C. Abandonment of the victim:

This applies if a healthcare professional leaves a patient in need of care without ensuring appropriate transfer of care. In this scenario, the nurse handed over the situation to EMS before leaving.

D. Good Samaritan immunity:

Good Samaritan laws protect individuals, including nurses, who voluntarily provide assistance in emergency situations from legal liability, as long as their actions are within the scope of their knowledge and training and are performed in good faith. The nurse stopped to help, provided care, and then reported to EMS personnel before leaving, which is consistent with the protection offered by Good Samaritan laws.

A. Auscultate the bowel sounds in all four quadrants. B. Palpate the client's pedal pulse volume bilaterally. C. Determine the elasticity of the client's skin turgor. D. Observe the client's skin and mucous membranes.

Correct Answer is D

Explanation

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

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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

Correct Answer is D

Explanation

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

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