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Nursing
When caring for a single client during one shift, it is appropriate for the
nurse to reuse only which of the following personal protective equipment?
1. Goggles
2. Gown
3. Surgical mask
4. Clean gloves - ANSWERS-Answer: 1. Rationale: Unless overly
contaminated by material that has splashed in the nurse's face and cannot
be effectively rinsed off, goggles
may be worn repeatedly (option 1). Since gowns are at high risk for
contamination, they should be used only once and then discarded or
washed (option 2). Surgical masks (option 3) and gloves (option 4) are
never washed or reused. Cognitive Level: Understanding. Client Need:
Safe, Effective Care Environment. Nursing Process: Implementation.
Learning Outcome: 31-11b.
While applying sterile gloves (open method), the cuff of the first glove rolls
under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to
take?
1. Remove the glove and start over with a new pair.
2. Wait until the second glove is in place and then unroll the cuff with the
other sterile hand.
,3. Ask a colleague to assist by unrolling the cuff.
4. Leave the cuff rolled under. - ANSWERS-Answer: 4. Rationale: It should
not be necessary to unroll this small edge of the cuff. The most important
consideration is the sterility of
the fingers and hand that will be used to perform the sterile procedure. The
rolled-under portion is now contaminated and should not be unrolled by the
nurse or colleague since it would then touch the remaining sterile portion of
the glove (option 3). Cognitive Level: Applying. Client Need: Safe, Effective
Care Environment. Nursing Process:
Implementation. Learning Outcome: 31-11d.
The nurse evaluates the chart of a 65-year-old client with no apparent risk
factors and concludes that which immunizations are current? Select all that
apply.
1. Last tetanus booster was at age 50
2. Receives a flu shot every year
3. Has not received the hepatitis B vaccine
4. Has not received the hepatitis A vaccine
5. Has not received the herpes zoster vaccine - ANSWERS-Answer: 2, 3,
and 4. Rationale: Flu shots are recommended for all adults over age 50.
Only adults at risk need to receive hepatitis B and A vaccine (note that this
is different than for children). Options 1 and 5 are incorrect because all
adults should receive a tetanus booster every 10 years (or sooner if
injured) and adults over age 60 should receive the herpes zoster
vaccination. Cognitive Level: Remembering. Client Need: Safe, Effective
Care Environment. Nursing Process: Assessment. Learning Outcomes: 31-
8; 31-6
A client with poor nutrition enters the hospital for treatment of a puncture
wound. An appropriate nursing diagnosis would be _____________. -
ANSWERS-Answer: Because a malnourished client with a wound is less
, able to resist an infection, Risk for Infection is the most likely nursing
diagnosis. Others may include Pain or Imbalanced Nutrition but they are
less focused on the immediate health risk. Cognitive Level: Applying. Client
Need: Safe, Effective Care Environment. Nursing Process: Diagnosing.
Learning Outcome: 31-7.
After teaching a client and family strategies to prevent infection prevention,
which statement by the client would indicate effective learning has
occurred?
1. "We will use antimicrobial soap and hot water to wash our hands at least
three times per day."
2. "We must wash or peel all raw fruits and vegetables
before eating."
3. "A wound or sore is not infected unless we see it
draining pus."
4. "We should not share toothbrushes but it is OK to share towels and
washcloths." - ANSWERS-Answer: 2. Rationale: Raw foods touched by
human hands can carry significant infectious organisms and must be
washed or peeled. Antimicrobial soap is not indicated for regular use and
may lead to resistant organisms. Hand hygiene should occur as needed.
Hot water can dry and harm skin, increasing the risk of infection (option 1).
Clients should learn all the signs of inflammation and infection (e.g.,
redness, swelling, pain, heat) and not rely on the presence of pus to
indicate this (option 3). People should not share washcloths or towels
(option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care
Environment. Nursing Process: Evaluation. Learning Outcomes: 31-8; 31-5.
The nurse determines that a field remains sterile if which of the following
conditions exist?
1. Tips of wet forceps are held upward when held in ungloved hands.