When the nurse is preparing a sterile field using the drape provided in a sterile pack, the nurse would only touch which part of the sterile drape?
The anterior surface of the drape.
The outer 1-inch border of the drape.
The top inner corners of the drape.
The posterior aspect of the drape.
The Correct Answer is A
Choice A rationale:
Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.
Choice B rationale:
This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.
Choice C rationale:
This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.
Choice D rationale:
This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. Retie the restraint straps with a slipknot.
Choice A rationale:
The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.
Choice B rationale:
It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.
Choice C rationale:
Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.
Choice D rationale:
The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.
Correct Answer is D
Explanation
Choice A rationale:
Confine the fire by closing doors and windows. Rationale: While confining the fire is essential, the nurse's first priority should be the safety of the client. Closing doors and windows can wait. The nurse should focus on immediate actions to ensure the client's safety.
Choice B rationale:
Activate the fire alarm system. Rationale: Activating the fire alarm system is crucial to alert others in the healthcare facility about the fire. This action ensures a timely response from the fire department and other staff members, enhancing overall safety within the facility.
Choice C rationale:
Extinguish the fire if possible. Rationale: Attempting to extinguish the fire might lead to delay, especially if the nurse is not trained to handle fires properly. Moreover, the nurse's safety is paramount, and attempting to put out the fire could put the nurse at risk. Prioritizing the client's immediate rescue is the best course of action.
Choice D rationale:
Rescue the client from immediate danger. Rationale: The correct action for the nurse to take first is to rescue the client from immediate danger. This may involve helping the client out of the room or moving them away from the source of the fire. Ensuring the client's safety is the top priority, and all other actions should follow after this.
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