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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. Keep their arms at the sides of their body with their hands in a relaxed position.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Clasp their hands together in a relaxed position behind their body at their waist.
- 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 keeps hands sterile and away from contamination.
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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.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Tortuous veins
- D. Clammy skin
Correct Answer: A
Rationale: Calf swelling is a key sign of deep-vein thrombosis, requiring immediate reporting for intervention.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Wear sterile gloves when handling the stool specimen.
- B. Have the client defecate into a bedpan that contains a small amount of water.
- C. Repeat the test three times using the same stool specimen.
- D. Ensure that the stool specimen does not contain urine.
Correct Answer: D
Rationale: Urine can contaminate the specimen, affecting the accuracy of the fecal occult blood test.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Removing the client's dentures from their mouth
- D. Closing the client's eyes
Correct Answer: C
Rationale: Removing dentures alters appearance unnaturally; they should remain unless otherwise specified.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has tuberculosis
- B. A client who has rubella
- C. A client who has had varicella
- D. A client who is HIV-positive
Correct Answer: C
Rationale: A client with prior varicella is immune to herpes zoster (same virus), minimizing transmission risk.