Nokea
The nurse is preparing to don sterile gloves. Which action should the nurse take to avoid contamination?
- A. Keep the hands above waist level.
- B. Select gloves that are one size larger than usual.
- C. Put on a sterile gown before donning the gloves.
- D. Don the sterile glove on the non-dominant hand first.
Correct Answer: A
Rationale: Keeping hands above waist level prevents contamination of sterile gloves by contact with non-sterile surfaces.
You may also like to solve these questions
The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action?
- A. Reinforce the dressing with paper tape
- B. Remove the dressing and the central vascular device
- C. Apply a clean occlusive dressing to the site
- D. Clean the site and apply a new sterile dressing
Correct Answer: D
Rationale: Cleaning the site and applying a new sterile dressing prevents infection and ensures catheter security.
The nurse is educating a client who has stomatitis on oral care. Which of the following recommendations would be appropriate?
- A. Recommend the client swish and spit alcohol mouthwash.
- B. Provide lemon glycerin swabs in between meals.
- C. Recommend the client swish and spit saline mouthwash.
- D. Instruct the client to cleanse their mouth with chlorhexidine.
Correct Answer: C
Rationale: Saline mouthwash soothes stomatitis without irritation. Alcohol mouthwash and lemon swabs are harsh, and chlorhexidine may be prescribed but isn’t the primary recommendation.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling?
- A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia
- B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide
- C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone
- D. 28-year-old admitted with bacteremia is receiving intravenous fluids via central line and is diaphoretic
Correct Answer: A
Rationale: The 88-year-old with dementia is at highest fall risk due to age and cognitive impairment.