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A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Clasp their hands together in a relaxed position behind their body at their waist.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist prevents glove contamination.
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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.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Use a filter needle to aspirate the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Cleanse the tip of the ampule with an alcohol swab after opening.
- D. Add 0.5 mL of diluent to the medication.
Correct Answer: A
Rationale: A filter needle prevents glass particles from entering the syringe.
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Overweight
- B. Underweight
- C. Ideal body weight
- D. Obese
Correct Answer: A
Rationale: A BMI of 25-29.9 is categorized as 'overweight.' This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
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.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.