Nokea
When removing a contaminated gown, what should be the first thing touched by the nurse?
- A. Waist tie and neck tie at the back of the gown
- B. Waist tie in front of the gown
- C. Cuffs of the gown
- D. Inside of the gown
Correct Answer: A
Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.
You may also like to solve these questions
Which of the following measures is not recommended to prevent pressure ulcers?
- A. Massaging the reddened area with lotion
- B. Using a water or air mattress
- C. Adhering to a schedule for positioning and turning
- D. Providing meticulous skin care
Correct Answer: A
Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.
Which of the following patients is at greater risk for contracting an infection?
- A. A patient with leukopenia
- B. A patient receiving broad-spectrum antibiotics
- C. A postoperative patient who has undergone orthopedic surgery
- D. A newly diagnosed diabetic patient
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct Answer: D
Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.
To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct Answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.
Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?
- A. Decreased blood pressure and heart rate and shallow respirations
- B. Quiet crying
- C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
- D. Changing position every 2 hours
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.