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. After each instruction, ask if the client understands:

While checking for understanding after each instruction is important, it may not accurately assess the client's ability to perform wound care independently. Verbal confirmation does not ensure competency in wound care techniques.

B. Have an interpreter repeat the wound care instructions:

Having an interpreter repeat the wound care instructions may help ensure accurate communication, but it does not assess the client's ability to perform the wound care independently.

C. Provide written instructions in the client's native language:

Providing written instructions in the client's native language can be helpful for reference, but it may not effectively assess the client's understanding or ability to perform the wound care.

D. Have the client demonstrate prescribed wound care:

This is the most appropriate method for evaluating the client's understanding of self-care at home. Having the client demonstrate wound care techniques allows the nurse to directly observe the client's competency in performing the necessary tasks. It provides a practical assessment of the client's ability to independently manage wound care post-discharge. If the client is unable to demonstrate the procedure correctly, the nurse can provide additional education and support as needed.

A. The client will demonstrate ability to change the ostomy bag in two days. B. The client will adhere to the medication regimen after discharge. C. The client's breath sounds will be auscultated by the nurse every 4 hours. D. The client attempts to self administer Insulin but is unable to perform injection.

Correct Answer is B

Explanation

A. The client will demonstrate ability to change the ostomy bag in two days.

This outcome statement focuses on the client's ability to perform a specific task related to ostomy care. While it's important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.

B. The client will adhere to the medication regimen after discharge.

This outcome statement directly addresses the client's need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client's health needs and goals following the surgical procedure and the development of hyperglycemia.

C. The client's breath sounds will be auscultated by the nurse every 4 hours.

This outcome statement focuses on monitoring the client's respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client's primary health concern in this scenario, which is managing hyperglycemia and insulin administration.

D. The client attempts to self-administer insulin but is unable to perform injection.

This outcome statement indicates the client's attempt to self-administer insulin but inability to perform the injection. While it's important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.

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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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Explanation

Correct Answer is B

Explanation

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