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

Removes needle before discarding used syringes.

Wears gloves to dispose of the needle and syringe.

Washes hands before handling the needle and syringe.

Dons a face mask before administering the medication.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because removing needle before discarding used syringes may expose the client or others to accidental needlestick injuries. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

Choice B Reason: This is incorrect because wearing gloves to dispose of the needle and syringe is not necessary if the client does not have contact with blood or body fluids. Gloves are not a substitute for hand hygiene.

Choice C Reason: This is correct because washing hands before handling the needle and syringe reduces the risk of infection and contamination. Hand hygiene is the most important measure to prevent transmission of microorganisms.

Choice D Reason: This is incorrect because donning a face mask before administering the medication is not required unless the medication is aerosolized or nebulized. A face mask does not protect against needlestick injuries or bloodborne pathogens.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.

Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.

Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.

Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.

A. Wait to obtain the specimen until observable blood is present. B. Withhold specimen collection until tarry black stool is observed. C. Obtain the specimen from the client's current bowel movement. D. Contact the healthcare provider before obtaining the specimen.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

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The nurse is teaching a client about use of the 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

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is A

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?

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?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Patient Data Exhibits Review H and P and nurse's notes. Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.