Nokea
A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gloves
- B. Goggles
- C. Gown
- D. Mask
Correct Answer: A
Rationale: Gloves are the first piece of personal protective equipment that the nurse should remove, as they are the most contaminated and can transfer microorganisms to other surfaces. The sequence then proceeds with goggles, gown, and mask to minimize contamination risk.
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A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Clean around the urinary meatus from front to back.
- B. Separate the labia with the nondominant hand.
- C. Insert the catheter into the urethral meatus.
- D. Secure the catheter to the client's thigh.
- E. Inflate the catheter balloon.
Correct Answer: A,B,C,E,D
Rationale: The correct order is: Clean the meatus (A), separate labia (B), insert catheter (C), inflate balloon (E), secure to thigh (D). This sequence minimizes infection risk and ensures proper placement.
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Increased convex curve of the cervical spine
- B. Increased concave curve of the thoracic spine
- C. Expansion of the upper intercostal spaces
- D. Unequal height of the shoulders
Correct Answer: D
Rationale: Unequal height of the shoulders is a classic sign of scoliosis due to spinal curvature. The other options indicate kyphosis, lordosis, or emphysema, respectively.
A nurse is caring for a client who has a hip fracture and plans to administer pain medication prior to turning the client. Which of the following ethical principles is the nurse implementing?
- A. Fidelity
- B. Beneficence
- C. Autonomy
- D. Veracity
Correct Answer: B
Rationale: Beneficence, the duty to do good and prevent harm, is implemented by relieving pain before a painful procedure. Fidelity, autonomy, and veracity involve promises, self-determination, and truthfulness, respectively.
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Witness the client's signature on a consent form.
- B. Obtain verbal consent from the client.
- C. Have another nurse co-sign the client's consent.
- D. Check the medical record for the client's signature on a previous consent form.
Correct Answer: B
Rationale: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it. Written consent is not required for this routine procedure, co-signing is unnecessary, and previous consent does not apply to the current procedure.
A nurse is reinforcing teaching with the adult children of a client who is receiving palliative care. Which of the following statements by one of the adult children indicates an understanding of the teaching?
- A. We will receive emotional support during our mother's illness.
- B. We will provide resuscitation to our mother if necessary.
- C. We won't discuss the illness in the presence of our mother.
- D. We won't allow her spiritual advisor to visit during this time.
Correct Answer: A
Rationale: Palliative care includes emotional support for families, which this statement reflects. Resuscitation contradicts palliative goals, and avoiding discussion or spiritual support misunderstands the holistic approach.