Which infection control actions would the nurse include in the use of standard precautions?

Masking before interviewing a patient about health history.

Gloving before wiping pink sputum off the bedrail.

Applying goggles before helping a patient to ambulate in the hall.

Gowning prior to delivering a food tray to a patient.

Answer and Explanation

The Correct Answer is B

Choice A: Masking before interviewing a patient about health history
Masking is generally used when there is a risk of exposure to respiratory droplets, such as when a patient has a known or suspected respiratory infection. However, it is not typically required for a standard health history interview unless there is a specific risk of exposure to infectious agents.
Choice B: Gloving before wiping pink sputum off the bedrail
This is the correct answer. Standard precautions include the use of personal protective equipment (PPE) such as gloves when there is a potential for contact with blood, body fluids, secretions, excretions, or contaminated items. Wiping pink sputum off the bedrail involves contact with potentially infectious material, making gloves necessary to prevent the spread of infection.
Choice C: Applying goggles before helping a patient to ambulate in the hall
Goggles or face shields are used when there is a risk of splashes or sprays of blood, body fluids, secretions, or excretions. Helping a patient to ambulate in the hall does not typically involve such risks, so goggles are not usually required in this scenario.
Choice D: Gowning prior to delivering a food tray to a patient
Gowns are used to protect skin and clothing from contamination when there is a risk of exposure to infectious material. Delivering a food tray to a patient does not generally pose such a risk, so gowning is not necessary for this task under standard precautions.

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Correct Answer is D

Explanation

Choice A: Apply wrist restraints to secure IV lines

Applying wrist restraints to secure IV lines should not be the first action. Restraints are generally considered a last resort due to their potential to cause harm and distress. They should only be used when absolutely necessary and after other interventions have failed. In this scenario, the patient’s agitation and confusion could be due to hypoxia, and addressing the underlying cause is more important than immediately resorting to restraints.

Choice B: Administer the prescribed opioid

Administering the prescribed opioid is not the first action to take. While pain management is crucial, opioids can sometimes exacerbate confusion and agitation, especially in the immediate postoperative period. It is essential to first assess the patient’s vital signs and oxygen levels to rule out hypoxia or other complications before administering any medication.

Choice C: Take the blood pressure and pulse

Taking the blood pressure and pulse is important but not the immediate first action. While these vital signs provide critical information about the patient’s cardiovascular status, checking the oxygen saturation is more urgent in this context. Hypoxia can lead to agitation and confusion, and addressing it promptly can stabilize the patient more effectively.

Choice D: Check the oxygen (O2) saturation

Checking the oxygen (O2) saturation should be the first action. Hypoxia is a common cause of postoperative agitation and confusion. By assessing the patient’s oxygen levels, the nurse can quickly determine if supplemental oxygen is needed, which can help alleviate the patient’s symptoms and prevent further complications. Ensuring adequate oxygenation is a priority in the immediate postoperative period.

A. Operative site B. Airway C. Pulse D. Skin integrity

Correct Answer is B

Explanation

Choice A reason:
Assessing the operative site is important to monitor for signs of bleeding, infection, or other complications. However, it is not the most critical, high-priority assessment immediately after surgery. While the condition of the surgical site can provide valuable information about the patient’s recovery and potential complications, it does not take precedence over ensuring the patient’s airway is clear and they are breathing adequately. The operative site can be assessed once the patient’s airway, breathing, and circulation are stable.
Choice B reason:
Airway assessment is the most critical, high-priority assessment in the PACU. Ensuring that the patient’s airway is clear and they are breathing properly is paramount because anesthesia can depress the central nervous system, leading to compromised airway patency and respiratory function. The primary goal in the immediate postoperative period is to ensure that the patient is ventilating adequately to prevent hypoxia and other respiratory complications. This involves checking for airway obstruction, monitoring respiratory rate, and ensuring that oxygen saturation levels are within normal ranges (typically 95-100% for healthy individuals). Any issues with the airway must be addressed immediately to prevent life-threatening complications.
Choice C reason:
Assessing the pulse is crucial for monitoring the patient’s cardiovascular status, including heart rate and rhythm. This can help detect arrhythmias, hypovolemia, or other cardiovascular issues that may arise postoperatively. However, while important, it is secondary to ensuring that the patient’s airway is clear and they are breathing adequately. The pulse can be assessed once the airway and breathing are confirmed to be stable. Normal pulse rates for adults typically range from 60 to 100 beats per minute.
Choice D reason:
Assessing skin integrity is important for identifying signs of pressure ulcers, infection, or other skin-related issues. However, this assessment is not the highest priority immediately after surgery. Ensuring the patient’s airway, breathing, and circulation are stable takes precedence. Skin integrity can be assessed once the patient is stable and other critical assessments have been completed. Maintaining skin integrity is essential for overall patient care, but it does not supersede the need to ensure the patient is breathing properly and has a clear airway.

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Which infection control actions would the nurse include in the use of standard precautions?

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Naxlex Comprehensive Predictor Exams

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Correct Answer is D

Explanation

The following 4 questions pertain to this case study: Exhibits In PACU, many assessments and interventions are done simultaneously. However, the most critical, high-priority assessment is:

Correct Answer is B

Explanation

The following 4 questions pertain to this case study: Exhibits Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?

The following 4 questions pertain to this case study: Exhibits The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Which statement best describes the nurse’s role in medication reconciliation?

The essential core of nursing practice is to deliver holistic, patient-centered care. This includes assessment and evaluation, providing a variety of interventions, patient and caregiver teaching, and being a member of the interprofessional healthcare team.

Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

Exhibits Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

Instructions: Use this scenario for the next 4 questions. Exhibits Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)