A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

Withdraws the medication from the ampule using a subcutaneous needle

Breaks the top of the ampule using an antiseptic wipe

Disposes of the ampule by placing it in a sharp’s container

Performs 3 checks of the medication before administration

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.

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Correct Answer is B

Explanation

A.Abiteblockisnottypicallyneededforaclientwithdysphagia,asitismorecommonlyusedinsituationswheretheairwayneedstobeprotected,suchasduringseizuresorcertaindentalprocedures.

B. A Yankauer suction device should be readily available for a client with dysphagia. Dysphagia increases the risk of aspiration, which can lead to choking or pneumonia. A Yankauer suction device allows for oral suctioning to clear secretions or food particles from the mouth and airway to help prevent aspiration and maintain a patent airway.

C. While large-handled utensils may be helpful for clients with limited dexterity or mobility (such as those with arthritis), they are not essential equipment for managing dysphagia.

D. Nasal cannula and oxygen: Oxygen therapy is not a routine intervention for dysphagia unless the client has respiratory complications that require supplemental oxygen. While aspiration can lead to respiratory issues like aspiration pneumonia, a nasal cannula and oxygen are not immediate necessities in the room for a client with dysphagia.

A. "I will have a client who is on airborne precautions wear a mask when out of her room." B. "I will place a client who has compromised immunity in a negative-pressure airflow room." C. "I will instruct visitors to wear a mask when visiting a client who is on contact precautions." D. "I will wear an N95 respirator mask when caring for a client who is on droplet precautions."

Correct Answer is A

Explanation

Choice A Reason:
Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.

Choice B Reason:
A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client. Negative-pressure rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.

Choice C Reason:
Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.

Choice D Reason:
An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.

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A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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