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A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?
- A. Isopropyl alcohol.
- B. Hydrogen peroxide.
- C. Chlorhexidine gluconate.
- D. Chlorine bleach.
Correct Answer: D
Rationale: Chlorine bleach effectively kills bloodborne pathogens like HIV and hepatitis B.
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A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
A nurse is caring for a client who is dying. One of the client's family members tells the nurse, 'I need to help. What can I do?' Which of the following actions should the nurse take?
- A. Suggest that the family member contact a grief counselor.
- B. Describe a personal experience with the death of a family member.
- C. Include the family member in providing care for the client.
- D. Ask if they have had prior experience with the death of a family member.
Correct Answer: C
Rationale: Involving the family member in care provides purpose and comfort.
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
- A. He appears anxious about the transfer.
- B. His partner has been visiting.
- C. He is voiding adequately.
- D. He is allergic to sulfa.
Correct Answer: D
Rationale: Allergy information is critical to prevent adverse reactions during care.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Avoid placing toilet tissue in the bedpan after defecation.
- B. Urinate after the specimen collection.
- C. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- D. Keep the specimen in a warm area.
Correct Answer: A
Rationale: Avoiding toilet tissue prevents contamination, ensuring specimen integrity.
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Restrict the number of visitors for clients.
- B. Turn on loud music in client care areas.
- C. Offer the clients many choices regarding care.
- D. Assign different nurses to provide care for clients each day.
Correct Answer: A
Rationale: Restricting visitors minimizes noise and stress, promoting a healing environment.