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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. Mask
- B. Gown
- C. Goggles
- D. Gloves
Correct Answer: D
Rationale: Gloves are removed first as they are most contaminated, preventing pathogen spread.
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A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Turn off alarms on bedside monitoring equipment.
- C. Avoid entering the client's room unless requested during the night.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: A
Rationale: Reducing noise by moving staff communication away enhances sleep without compromising safety.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Contact facility security to remove the nurse from the unit.
- B. Complete an incident report about the breach of confidentiality.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Tell the nurse that permission from the risk manager is required to view the client's record.
Correct Answer: C
Rationale: Reminding the nurse about confidentiality reinforces HIPAA compliance without escalating unnecessarily.
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 has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I can expect to have regular periods until I am in menopause.
- C. The best time to perform a breast self-examination is on the first day of my period.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: A
Rationale: Declining estrogen in perimenopause can cause headaches, reflecting hormonal changes.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma bleeds lightly when touched.
- D. The stoma appears dark in color.
Correct Answer: D
Rationale: A dark stoma indicates potential necrosis or ischemia, requiring immediate provider attention.