A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Disposes of contaminated sheets in a linen bag

Wears clean gloves when performing oral hygiene

Empties the sharps container when it is full

Wears an N95 mask when bathing a client who has Clostridium difficile

Answer and Explanation

The Correct Answer is B

A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.

B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.

C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.

D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.

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Correct Answer is C

Explanation

A. Dry excess sanitizer from hands with a paper towel: Hand sanitizer should be allowed to dry naturally, and there is no need to wipe it off with a paper towel. Wiping off the sanitizer could reduce its effectiveness in killing germs.

B. Rubs hands together for 10 seconds after applying sanitizer: The Centers for Disease Control and Prevention (CDC) recommends rubbing hands together for at least 20 seconds to ensure that the hand sanitizer covers all surfaces of the hands and effectively kills germs.

C. Apply enough sanitizer to completely cover both hands: It is important to apply a sufficient amount of hand sanitizer (usually about a dime-sized amount) to cover both hands entirely. The sanitizer should be rubbed into all areas of the hands, including between fingers and under nails, until the hands are dry.

D. Clean sanitizer from under fingernails using an orangewood stick: This is unnecessary if the sanitizer is applied properly and rubbed in completely. Hand sanitizer should be used to cover all areas of the hands, including under fingernails, and should be allowed to dry naturally without needing to clean it with a stick.

A. Assist with administration of AB positive blood products if needed. B. Prepare client for insertion of 18-gauge peripheral IV prior to surgery. C. Administer Rh, D immune globin prior to surgery. D. Obtain a complete blood count. E. Explain the surgical procedure to the client. F. Remind client to be NPO prior to surgery. G. Verify consent form is signed by the client.

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

Explanation

Prepare client for insertion of 18-gauge peripheral IV prior to surgery: A large-bore IV catheter, such as an 18-gauge, is necessary before surgery to ensure rapid administration of fluids, medications, or blood products if needed during the procedure. It is a measure to support hemodynamic stability during anesthesia and surgery.
Administer Rh, D immune globin prior to surgery: The client's blood type is B negative. Because an ectopic pregnancy involves fetal tissue, and there's a potential for fetal-maternal blood mixing during the surgery, administering Rh(D) immune globulin (RhoGAM) is crucial to prevent Rh sensitization in Rh-negative women who may be carrying an Rh-positive fetus. This is typically given within 72 hours of a potential sensitizing event.
Obtain a complete blood count: A CBC is critical to assess hemoglobin, hematocrit, and platelet levels before surgery. This helps the healthcare team anticipate the risk of bleeding and determine if transfusions might be necessary during or after the laparoscopic procedure.
Explain the surgical procedure to the client: Explaining the surgical procedure is the provider's responsibility, not the nurse's role. The nurse can reinforce teaching and answer basic questions but should not be the primary person explaining the procedure or obtaining informed consent.
Remind client to be NPO prior to surgery: Maintaining NPO status is essential to reduce the risk of aspiration during anesthesia. The client should avoid eating or drinking for a specified time before surgery, following the facility's preoperative protocol.
Verify consent form is signed by the client: Verifying that the informed consent form is properly signed is a crucial nursing responsibility before surgery. It ensures legal compliance and confirms that the client has been informed about the procedure, risks, and alternatives.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the development of a staff in-service about hand hygiene. The nurse should include which of the following instructions regarding the use of hand sanitizer?

Correct Answer is C

Explanation

The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. The nurse is preparing the client for surgery. Which of the following actions should the nurse take. Select all that apply.

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

Explanation

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