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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

A. Place the client in a room with positive airflow. B. Determine whether the client lives alone or with others. C. Use an alcohol-based hand cleaner unless hands are visibly soiled. D. Remind the client to cover her mouth with a tissue when coughing.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Placing a client with active pulmonary TB in a room with positive airflow is not recommended, as positive airflow would push potentially contaminated air into general circulation, risking the spread of TB. Instead, a room with negative airflow is appropriate to contain and remove contaminated air.

Choice B reason: Determining whether the client lives alone or with others is important for public health and contact tracing purposes. If the client lives with others, those individuals may need to be tested and monitored for TB as well.

Choice C reason: Using an alcohol-based hand cleaner is a standard practice unless hands are visibly soiled. If hands are visibly soiled, handwashing with soap and water is necessary.

Choice D reason: Reminding the client to cover their mouth with a tissue when coughing is a key measure to prevent the spread of TB, which is transmitted through airborne particles from coughs or sneezes.

Choice E reason: Antifungal medications are not used to treat TB, which is caused by a bacterium, not a fungus. The client should be instructed about taking anti-tuberculosis medications, not antifungals.

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A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Correct Answer is D

Explanation

A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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