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A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The sterile solution is poured with the bottle held over the field.
- B. Unnecessary sterile items are placed on the field.
- C. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: A
Rationale: Pouring solution with the bottle over the field risks contamination from touch or splash.
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A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client is sedentary throughout most of the day.
- C. The client has no living family.
- D. The client has poorly fitting dentures.
Correct Answer: D
Rationale: Poorly fitting dentures can impair nutrition, posing an immediate health risk.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Request that the provider sign the consent form.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: In emergencies, implied consent allows life-saving procedures when delaying could harm the client.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To a medical interpreter service on behalf of a client
- B. To a family member when the client is not available
- C. To an employer for a pre-employment screening
- D. To an insurance agency in regard to a life insurance policy
Correct Answer: A
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Measure the intake and output of a client who has received furosemide.
- B. Assess the pain level of a client who has received acetaminophen.
- C. Reinforce teaching with a client about crutch-gait walking.
- D. Check a client's peripheral IV site for redness or swelling.
Correct Answer: A
Rationale: Measuring intake and output is within the AP’s scope and appropriate for delegation.