A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)

Emptying a urinary drainage bag for a client who has pneumonia

Suctioning a client's new tracheostomy tube

Irrigating a client's abdominal wound

Providing hygiene care to a client who is HiV-positive

Transporting a cerebrospinal fluid specimen to the Laboratory

Answer and Explanation

Correct Answer : B,C

A) Emptying a urinary drainage bag for a client who has pneumonia:
Wearing protective eye equipment is not necessary for emptying a urinary drainage bag. Standard precautions for handling bodily fluids would apply, but there is no expected risk for splashes to the eyes when performing this task. Gloves and hand hygiene are essential, but eye protection is not typically required.

B) Suctioning a client's new tracheostomy tube:
When suctioning a client's tracheostomy tube, there is a significant risk of splashing or spraying bodily fluids, including mucus, that may contain infectious particles. Wearing protective eye equipment is necessary to prevent potential contamination of the eyes from bodily fluids during this procedure. This is a high-risk task for exposure.

C) Irrigating a client's abdominal wound:
Irrigating an abdominal wound carries a risk of splashing bodily fluids, particularly when fluids are under pressure or if the wound is large. To avoid exposure to infectious material, the nurse should wear protective eye equipment to prevent any risk of fluids coming into contact with the eyes.

D) Providing hygiene care to a client who is HIV-positive:
Providing hygiene care to a client who is HIV-positive does not pose a significant risk to the nurse’s eyes, as HIV is transmitted through blood and certain body fluids under specific conditions. While gloves and other precautions are necessary, protective eye equipment is not required for standard hygiene care unless there is a specific risk of splashing.

E) Transporting a cerebrospinal fluid specimen to the laboratory:
When transporting cerebrospinal fluid (CSF), the primary concern is ensuring the specimen is properly contained to prevent leaks or spills. While gloves should be worn to handle the specimen, there is no direct risk of exposure to the eyes unless there is a spill. In such a case, the nurse would need to protect their eyes, but wearing protective eyewear during transport is not routinely required.

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Correct Answer is C

Explanation

A) "I will place an area rug at the entry of my bathroom": This statement indicates a misunderstanding of safety guidelines. Rugs, especially if they are not properly secured, can pose a tripping hazard. It is recommended to avoid area rugs in high-risk areas like the bathroom to prevent falls.

B) "I will keep the fluorescent ceiling light on in my room at night": While adequate lighting is essential for fall prevention, leaving a bright fluorescent light on can lead to glare and difficulty with vision at night, potentially increasing the risk of a fall. A nightlight or low-level lighting near the bed or bathroom would be more appropriate.

C) "I will place a bath seat in my shower to use when I bathe": This statement indicates that the client understands the need for safety measures to prevent falls. Using a bath seat in the shower allows the client to sit while bathing, reducing the risk of slipping or losing balance, particularly if they are at risk for falls or have difficulty standing for long periods.

D) "I will keep my walker at the end of my bed": This action could be unsafe because the client might need to walk a distance to retrieve the walker when getting out of bed, which increases the risk of a fall. The walker should be kept within easy reach, such as near the bedside, to ensure it is available immediately when the client needs to get up.

A. Obtain a bedside commode for the client's use B. Leave a nightlight on in the client's room C. Limit the client's fluid intake in the evening. D. Put the side rails up and tell the client to call the nurse before voiding

Correct Answer is B

Explanation

A) Obtain a bedside commode for the client's use: While a bedside commode may be helpful for reducing the need for the client to walk to the bathroom, it may not fully address the client's concern about falling. The most immediate solution to improve safety during the night would be ensuring that the environment is adequately lit and easy to navigate. The bedside commode could be considered, but a nightlight would be the first step.

B) Leave a nightlight on in the client's room: This is the best action to take in this situation. A nightlight will improve visibility and help the client navigate safely to the bathroom at night. Falls are more common in low-light environments, and a nightlight can provide the needed illumination to reduce the risk of tripping or losing balance during the night.

C) Limit the client's fluid intake in the evening: While limiting fluid intake may reduce the frequency of nighttime trips to the bathroom, it is not an ideal or holistic solution. Reducing fluid intake can also lead to dehydration, which can cause other health issues. The focus should be on creating a safe environment for the client to move about, rather than restricting essential fluids.

D) Put the side rails up and tell the client to call the nurse before voiding: Raising the side rails can increase the risk of entrapment and restrict the client's ability to move freely if they need to get out of bed. Telling the client to call the nurse may also delay their ability to respond to their needs promptly, especially in the middle of the night. Instead, ensuring a safer environment and encouraging independence, with appropriate safety measures like a nightlight, is more effective.

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A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)

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