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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. Gloves
- B. Goggles
- C. Gown
- D. Mask
Correct Answer: A
Rationale: Gloves are the first piece of personal protective equipment that the nurse should remove, as they are the most contaminated and can transfer microorganisms to other surfaces. The sequence then proceeds with goggles, gown, and mask to minimize contamination risk.
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A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Witness the client's signature on a consent form.
- B. Obtain verbal consent from the client.
- C. Have another nurse co-sign the client's consent.
- D. Check the medical record for the client's signature on a previous consent form.
Correct Answer: B
Rationale: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it. Written consent is not required for this routine procedure, co-signing is unnecessary, and previous consent does not apply to the current procedure.
A nurse is providing teaching with a client who has severe arthritis and has difficulty with stairs. What should the nurse include in the teaching?
- A. Keep your eyes on your feet when ascending or descending the stairs.
- B. Maintain your arms in a slightly bent position when using the handrails.
- C. Move your right leg forward as you lower yourself to the next step.
- D. Support yourself with the handrail when transferring to or from the stairs.
Correct Answer: B
Rationale: Maintaining arms in a slightly bent position when using handrails enables the client to use them as support and reduces stress on the arms and shoulders. The other options can lead to imbalance, instability, or strain.
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. Turn on loud music in client care areas.
- B. Assign different nurses to provide care for clients each day.
- C. Offer the clients many choices regarding care.
- D. Restrict the number of visitors for clients.
Correct Answer: D
Rationale: Restricting the number of visitors can reduce noise and overstimulation, promoting a calm environment. Loud music, inconsistent staffing, and excessive choices can increase stress.
A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?
- A. Remove blankets from the client.
- B. Place cold packs on the client's axillae.
- C. Place a fan to blow air across the client.
- D. Give the client an alcohol sponge bath.
Correct Answer: A
Rationale: Removing blankets helps the client lose heat and reduce fever. Cold packs, fans, or alcohol baths can cause complications like shivering or toxicity.
A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?
- A. Request that the caller contact the client's provider directly for information.
- B. Ask the caller to contact the client directly for information.
- C. Gather additional information from the caller to verify their identity.
- D. Provide the caller with a brief update about the client's condition.
Correct Answer: C
Rationale: Gathering information to verify the caller's identity ensures compliance with privacy laws (e.g., HIPAA) before sharing information. Redirecting the caller or providing updates without verification risks breaching confidentiality.