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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. Gown
- B. Goggles
- C. Mask
- D. Gloves
Correct Answer: D
Rationale: Gloves are removed first as they are the most contaminated, reducing spread.
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A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has an elevated hemoglobin level.
- B. The client is wearing nail polish.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: B
Rationale: Nail polish, especially dark colors, can block the pulse oximeter sensor, affecting accuracy.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Grasp the outermost flap of the sterile kit while opening away from the body.
- B. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- C. Open each side flap of the sterile kit individually while pulling to the side.
- D. Prepare a dry work surface above the waist level.
- E. Open the outside cover of the sterile kit and remove the dust cover.
Correct Answer: D,E,A,C,B
Rationale: D: Set up surface. E: Remove cover. A: Open outermost flap. C: Open side flaps. B: Open innermost flap maintains sterility.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Provide oral care to the client once every 8 hr.
- B. Use a fan to circulate air in the client's room.
- C. Reposition the client once every 4 hr.
- D. Place the head of the client's bed flat.
Correct Answer: B
Rationale: A fan circulates air, relieving dyspnea by enhancing the feeling of airflow.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Occupational therapist
- B. Registered dietitian
- C. Respiratory therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: A speech-language pathologist is specifically trained to evaluate and treat swallowing disorders (dysphagia), which makes them the appropriate specialist for this referral.