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 B

Explanation

A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.

B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.

C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.

D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.

A. Request the family members leave the client's room B. Place dentures in the client's mouth. C. Remove the client's personal hair pieces. D. Lower the head of the client's bed.

Correct Answer is B

Explanation

A. Request the family members leave the client's room: Family members may choose to stay if they wish, and they should be allowed to participate or be present during postmortem care if it aligns with their emotional needs or cultural practices. Forcing them to leave is not appropriate unless required for specific procedures.

B. Place dentures in the client's mouth: Placing dentures helps maintain the natural shape and appearance of the face, offering a more familiar and comforting appearance for the family during viewing. This is an important step in preparing the body respectfully.

C. Remove the client's personal hair pieces: Hairpieces should be left in place unless the family or facility policy requests otherwise. Removing them without need can alter the client’s appearance and potentially distress the family.

D. Lower the head of the client's bed: The head of the bed should be elevated slightly, not lowered, to prevent blood from pooling in the head and face, which could cause discoloration and swelling before the family views the body.

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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

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Explanation

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Explanation

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