Nokea
The nurse is conducting a staff conference regarding standard precautions. It would be correct for the nurse to state that hand washing with soap and water is required when
- A. Hands are visibly soiled.
- B. Collecting vital signs (VS).
- C. Performing range of motion exercises.
- D. Inputting data into the electronic medical record (EMR).
Correct Answer: A
Rationale: Soap and water are required for visibly soiled hands, as alcohol-based rubs are less effective. Other activities can use hand rubs unless soiled.
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The nurse is preparing to administer an enema to a client who is experiencing constipation. Place the following actions in the order listed:
- A. Lubricate the tip of the enema applicator
- B. Remove the applicator after the solution has been infused.
- C. Explain the procedure and help the client lie on the left side with their knees flexed and back toward you
- D. Release clamp
- E. Insert into the client's rectum
- F. Fill the enema bag, prime, and clamp tubing
Correct Answer: F,A,C,E,D,B
Rationale: The correct order is: fill and prime bag (F), explain and position client (C), lubricate tip (A), insert tube (E), release clamp (D), remove applicator (B). This ensures safe administration.
The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Tofu
- C. Almonds
- D. Prunes
- E. Baked fish
- F. Grapefruit
Correct Answer: A,B,C,D,F
Rationale: Vegan diets exclude animal products, so legumes, tofu, almonds, prunes, and grapefruit are suitable. Baked fish is not vegan.
Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm?
- A. Ozone
- B. Nitrous oxide
- C. Carbon monoxide
- D. Carbon dioxide
Correct Answer: C
Rationale: Carbon monoxide detectors are widely available, inexpensive, and similar to smoke alarms, detecting a colorless, odorless gas that poses a significant health risk. Ozone, nitrous oxide, and carbon dioxide detectors are less common in homes.
A nurse is preparing a client's intravenous (IV) infusion. As the nurse was preparing to attach the distal end of the IV tubing to the client's needleless access device, the exposed tubing slipped and hit the top of the client's bedside table. Which of the following is the most appropriate action by the nurse?
- A. Replace the IV tubing with new tubing
- B. Discard the client's current needleless access device and replace it with a new one
- C. Wipe the distal end of the tubing with povidone-iodine to render it sterile
- D. Clean the needleless access device with an alcohol swab
Correct Answer: A
Rationale: Replacing the tubing ensures sterility after contact with a non-sterile surface.
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.