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The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
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The nurse is planning to perform a dressing change for a client with a stage three pressure injury. The nurse should initially perform which action?
- A. Gather all the necessary equipment
- B. Use non-sterile gloves to remove the old dressing
- C. Document the characteristics of the wound
- D. Administer prescribed oral pain medication
Correct Answer: A
Rationale: Gathering equipment ensures efficiency and sterility. Non-sterile gloves, documentation, and pain medication follow preparation.
The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.
The nurse cares for a client in the outpatient surgical center who is scheduled for a cholecystectomy
Item 1 of 1
Nurses' Note
0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment.Select the findings on the assessment that require follow-up
- A. ID verified and band applied
- B. The surgeon has not obtained informed consent
- C. Client took his prescribed phenytoin with a sip of water this morning
- D. The client reports his last meal and fluid intake was the previous day at 2200
- E. The client stated he was going to drive himself home after the procedure
Correct Answer: B,D
Rationale: Assessment items requiring follow-up include the informed consent not yet obtained by the surgeon. Before further preoperative activities may continue, the nurse must ensure this is completed to avoid unnecessary diagnostic testing and intervention. Additionally, the client will not be permitted to drive themselves home after this procedure because this involves general anesthesia. Activities requiring significant concentration, operation of heavy machinery, or driving are typically prohibited 24 hours following the initiation of general anesthesia.
The other assessment findings do not require intervention. ID banding and verification are expected during the preoperative process. The client's ID will also be verified in the intraoperative and postoperative processes. Medications such as phenytoin can be taken with a sip of water to prevent seizure activity. The client has been NPO for approximately eight hours, sufficient time to prevent aspiration.
The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions?
- A. Droplet precautions
- B. Airborne and contact precautions
- C. Contact and droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Varicella zoster requires airborne and contact precautions due to its transmission via respiratory droplets and direct contact. Other options are insufficient.
While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedimiento?
- A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool.
- B. The head of the bed flat with the patient lying on the unaffected side.
- C. Prone position with both arms extended above the head.
- D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.
Correct Answer: A
Rationale: Sitting up and leaning forward maximizes lung expansion and pleural fluid access for thoracentesis. Other positions restrict access or increase complication risk.