Question

A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Answer 1

Correct Answers:

Changing a central venous catheter dressing for a client who is receiving IV therapy

Rationale :

🧤A central line provides direct access to the bloodstream, so maintaining a sterile field is essential to prevent bloodstream infections.

🩹Using sterile gloves during dressing changes minimizes the risk of introducing pathogens into the catheter insertion site.

✍️Other procedures—instilling ophthalmic ointment, inserting an NG tube, administering an IM injection—occur in nonsterile body areas or involve only clean technique.

✔️Evidence-based guidelines mandate aseptic technique for all central line care to reduce infection-related morbidity.

📌Core Message

Sterile gloves are mandatory for central line dressing changes to prevent bloodstream infections.

Answer 2

Correct Answers:

Interlace the fingers while rubbing hands together.

Rationale :

🖐️Interlacing fingers during hand hygiene cleans the interdigital spaces, where microorganisms commonly reside.

✨This step increases friction at skin folds, enhancing pathogen removal.

⏳Thorough handwashing requires covering all surfaces, including nail beds and fingertips.

🔄Interlacing is a key component of the surgical scrub sequence to reduce infection transmission.

📌Core Message

Interlacing fingers during hand hygiene removes microorganisms from interdigital areas.

Answer 3

Correct Answers:

Urinary retention

Rationale :

💊Morphine increases sphincter tone and suppresses the micturition reflex, leading to urinary retention.

🌡️Opioid-induced smooth muscle relaxation impairs bladder emptying, causing urinary stasis.

⚠️Untreated retention can result in bladder distension, infection, and renal impairment.

📋Monitoring urinary output is essential when administering opioid analgesics.

📌Core Message

Opioid analgesics like morphine can cause urinary retention by increasing sphincter tone.

Answer 4

Correct Answers:

Believes his bad behavior is causing his brother's death

Rationale :

🧠School-age children often use magical thinking, believing their thoughts or actions can influence events.

😔This leads to self-blame and guilt when coping with a sibling’s terminal illness.

👥Their understanding of causality is still developing, so they assume responsibility for uncontrollable outcomes.

💭Such thinking is a normal part of cognitive development as they process trauma.

📌Core Message

Magical thinking can cause school-age children to self-blame during a sibling’s terminal illness.

Answer 5

Correct Answers:

"I should discuss this document with my family after I sign it."

Rationale :

🗣️Discussing advance directives with family ensures clarity about the client’s end-of-life wishes.

🔄Clients retain the right to revise or revoke their directives at any time if they remain competent.

📜Witness and notarization requirements vary by jurisdiction, so a partner’s presence or attorney involvement isn’t universally mandatory.

✅Family awareness reduces confusion and promotes adherence to the client’s preferences.

📌Core Message

Family discussion ensures advance directives reflect and respect the client’s end-of-life preferences.

Answer 6

Correct Answers:

New onset of hearing loss

Rationale :

🦻Gentamicin is ototoxic, damaging inner ear hair cells and leading to hearing loss.

📊This effect can be irreversible, so baseline and ongoing audiometric testing are essential.

⚖️Monitoring for tinnitus or balance disturbances helps detect ototoxicity early.

🚫Hypotension, hyperthermia, and slurred speech are not typical aminoglycoside adverse effects.

📌Core Message

Aminoglycosides like gentamicin can cause ototoxicity, resulting in hearing loss.

Answer 7

Correct Answers:

Measure the client's vital signs.

Rationale :

🩺Assessing vital signs immediately after a fall identifies potential injuries such as head trauma or shock.

⏱️Timely evaluation of blood pressure, heart rate, and respiratory status guides further interventions.

📑Documentation and incident reporting follow the initial assessment findings.

🔄Notifying the provider depends on abnormal assessment results, ensuring appropriate clinical response.

📌Core Message

The first action following a fall is to assess vital signs for potential acute injuries.

Answer 8

Correct Answers:

Is eager to review the birth experience

Rationale :

🍼During the taking-in phase, mothers are dependent and focus on recounting their birth experience.

🗣️They often seek to share details and process the emotions surrounding labor and delivery.

🤱Physical self-care and independence are secondary as they integrate their new maternal role.

🔄Subsequent phases involve taking hold (assuming self-care) and letting go (reconnecting with family).

📌Core Message

In the taking-in phase, new mothers focus on recounting their birth experience.

Answer 9

Correct Answers:

Encourage the family to express their feelings of loss.

Rationale :

💬Facilitating emotional expression aids the family’s grieving process and provides support.

🤝This approach fosters a therapeutic alliance by validating their feelings.

🌎Respecting cultural and religious practices ensures the care aligns with family needs.

🕰️Allowing time for grief is more beneficial than imposing restrictions or distancing them from their loved one.

📌Core Message

Facilitating emotional expression helps families navigate the grieving process.

Answer 10

Correct Answers:

The client makes funeral arrangements.

Rationale :

⚰️Engaging in funeral planning signifies acceptance of impending death and a sense of hopelessness.

💔A decrease in energy alone may reflect fatigue, not necessarily hopelessness.

🔍Requesting a second opinion demonstrates seeking information, not despair.

🗣️Wanting to talk about the diagnosis indicates engagement, not a loss of hope.

📌Core Message

Planning a funeral reflects hopelessness and acceptance of death.

1 :
A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

2 :
A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

3 :
A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

4 :
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

5 :
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

7 :
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

8 :
A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

9 :
A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

1 : A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

2 : A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

3 : A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

4 : A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

5 : A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

6 : A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

7 : A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

8 : A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

9 : A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

10 : A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

1 :
A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

2 :
A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

3 :
A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

4 :
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

5 :
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

7 :
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

8 :
A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

9 :
A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?