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","D","E"]

Explanation

Choice A: Lead the client in guided imagery

This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.

Choice B: Give a dose of 2.5 mg of Morphine

This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.

Choice C: Assist the client to walk around the room

This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.

Choice D: Assess for sources of pain other than the surgical site

This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.

Choice E: Consult with the surgeon about the pain level

This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.

A. Notify the healthcare provider. B. Document the event on the chart. C. Complete an incident report. D. Inform the nurse on the next shift.

Correct Answer is A

Explanation

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

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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

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is A

Explanation

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