A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?
Providing a newborn's first bath
Giving personal care to an infant who is HIV-positive
Suctioning secretions from a child's newly placed tracheostomy tube
Withdrawing cord blood from a neonate
Transporting a cerebrospinal fluid specimen to the laboratory
The Correct Answer is C
Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.
Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.
Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.
Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.
Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.
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Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Expecting the client to express pain both verbally and nonverbally is important in postoperative care. Pain expression is subjective and can vary greatly among individuals. Some clients may verbalize their discomfort, while others may exhibit nonverbal cues such as grimacing, restlessness, or guarding the affected area. It is crucial for nurses to be attentive to all forms of pain expression to assess and manage the client's pain effectively.
Choice B reason: Administering opioids with caution is a standard practice due to the risk of addiction; however, the statement that they will eventually lead to addiction is misleading. Opioids, when used appropriately and under medical supervision, are an effective component of postoperative pain management. The risk of addiction is present but can be mitigated through careful monitoring, patient education, and using the lowest effective dose for the shortest duration necessary.
Choice C reason: Administering analgesics orally for fast-acting pain relief is a common practice, especially when immediate onset is not required. Oral administration is non-invasive and convenient, but it is not the fastest method for pain relief compared to intravenous administration. The choice of analgesic and the route of administration should be based on the client's pain level, type of surgery, and individual needs.
Choice D reason: Using a pain scale from 0 to 10 is an effective way to monitor the severity of the client's pain. This method provides a quantifiable measure of pain intensity, allowing for consistent assessment and facilitating communication between the client and healthcare providers. It helps in evaluating the effectiveness of pain management interventions and in making necessary adjustments to the pain management plan.
Choice E reason: Considering the client's individual expression of pain is essential in postoperative care. Pain is a personal experience, and what may be tolerable for one person could be unbearable for another. Factors such as cultural background, previous pain experiences, psychological state, and the presence of comorbidities can influence pain perception. Tailoring pain management strategies to the individual's needs and preferences is key to effective pain control.
Correct Answer is A
Explanation
Choice A reason: Avoiding large amounts of fluids before bedtime can help prevent disruptions in sleep due to the need to urinate during the night.
Choice B reason: Consuming alcohol, even in the form of a glass of wine, just before bedtime can interfere with the sleep cycle and lead to disrupted sleep.
Choice C reason: Engaging in brisk exercise before bedtime can be stimulating and may make it more difficult to fall asleep.
Choice D reason: Performing muscle relaxation techniques in the afternoon can help reduce overall tension but doing them closer to bedtime would be more beneficial for promoting sleep.
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