Nokea
The charge nurse is observing infection control practices in the nursing unit. Which observation by the charge nurse requires follow-up? Select all that apply.
- A. Soiled linens are placed on the floor during a bed bath and linen change.
- B. A disposable blood pressure cuff is used for a client on contact precautions.
- C. Disposable dishes are placed in the room for a client on droplet precautions.
- D. Reusable eye protection is cleaned and disinfected after each client encounter.
- E. A surgical hand scrub is performed with the hands lower than the elbows.
- F. Gloves are doffed last while removing personal protective equipment (PPE).
Correct Answer: A,E,F
Rationale: Soiled linens on the floor risk contamination, hands should be higher than elbows during surgical scrub, and gloves should be doffed first to prevent contamination.
You may also like to solve these questions
The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test?
- A. Urine specific gravity
- B. Liver function tests
- C. Blood glucose
- D. Creatine kinase
Correct Answer: C
Rationale: PET scans often use glucose-based tracers, so blood glucose levels must be checked to ensure accurate imaging. Other labs are not routinely required.
The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.
The nurse instructed a client discharged with crutches on how to use the stairs. Which statement by the client indicates a correct understanding of the teaching?
- A. I should hold the handrail for support with one hand.
- B. When going up the stairs, I should lead with my crutches and weaker leg.
- C. When going down the stairs, I should lead with my crutches and strong leg.
- D. I should remove the rubber tip when going up and down the stairs.
Correct Answer: A
Rationale: Holding the handrail provides stability. Ascending requires leading with the stronger leg, descending with crutches and weaker leg, and rubber tips remain on.
The nurse is teaching a client with hypothyroidism. The nurse should recommend that the client increase their intake of foods rich in
- A. Fiber.
- B. Saturated fats.
- C. Calcium.
- D. Potassium.
Correct Answer: A
Rationale: Fiber aids digestion, often slowed in hypothyroidism. Saturated fats, calcium, and potassium are not specifically indicated.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.