A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

"I will wear gloves and a gown when bathing a client who has open skin lesions."

"I will wear gloves when measuring a client's blood pressure."

"I will wear gloves whenever I am in contact with clients."

1 will wear gloves to minimize the number of times I have to wash my hands."

Answer and Explanation

The Correct Answer is A

A. "I will wear gloves and a gown when bathing a client who has open skin lesions.": This statement indicates an understanding of the appropriate use of personal protective equipment (PPE) in a situation where there is a risk of exposure to blood or bodily fluids. Wearing gloves and a gown helps protect the AP from potential pathogens present in the client's open skin lesions.

B. "I will wear gloves when measuring a client's blood pressure.": While it may be appropriate to wear gloves for certain procedures, it is not universally required to wear gloves when measuring blood pressure unless there are specific concerns about contamination or exposure to body fluids. This statement does not demonstrate a clear understanding of when gloves are necessary.

C. "I will wear gloves whenever I am in contact with clients.": This statement suggests a lack of understanding of the appropriate use of gloves. Gloves should be used when there is a risk of contact with blood, body fluids, or open wounds, but they are not necessary for all interactions with clients, especially if there is no risk of contamination.

D. "I will wear gloves to minimize the number of times I have to wash my hands.": This statement indicates a misunderstanding of the primary purpose of gloves. Gloves are used to protect both the caregiver and the client from infection, and hand hygiene should still be performed before and after glove use. The focus should be on infection control rather than convenience.

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Correct Answer is A

Explanation

A. The client faces the direction of movement when sliding an object across the floor: This finding indicates that the client is using proper body mechanics. Facing the direction of movement helps maintain balance and reduces the risk of injury when sliding or moving objects.

B. When moving an object to one side, the client puts his weight on his heels: Putting weight on the heels can lead to a loss of balance and stability. Proper body mechanics involve distributing weight evenly and maintaining a stable base, which is not reflected in this finding.

C. When pushing an object, the client moves his front foot backward: This action is not a proper body mechanic. When pushing, the client should maintain a stable stance with feet positioned appropriately to provide support and leverage. Moving the front foot backward may compromise stability.

D. The client stands with his feet close together when lifting an object: Standing with feet close together can decrease stability and increase the risk of falls. Proper body mechanics recommend a wider stance for better support and balance when lifting or moving objects.

A. The client is attempting to remove the restraint. B. The client has full range of motion in her wrist. C. The client's hand is cool and pale. D. The client has a capillary refill of less than 2 seconds.

Correct Answer is C

Explanation

A. The client is attempting to remove the restraint: While this may indicate discomfort or agitation, it does not necessarily warrant loosening the restraint. The nurse should assess the underlying reasons for the client's behavior but may need to keep the restraint in place for safety if the client poses a risk to themselves or others.

B. The client has full range of motion in her wrist: Having full range of motion does not indicate a need to loosen the restraint. The primary concern with restraints is ensuring the client's safety and comfort while monitoring for signs of circulation and proper function.

C. The client's hand is cool and pale: This finding is concerning and indicates potential impaired circulation due to the restraint being too tight. Loosening the restraint is essential in this case to restore circulation and prevent further complications. Coolness and paleness are signs of inadequate blood flow and require immediate action to ensure the client’s safety.

D. The client has a capillary refill of less than 2 seconds: A capillary refill of less than 2 seconds typically indicates good circulation. While monitoring capillary refill is important, this finding alone does not warrant loosening the restraint. The priority is to respond to any indications of compromised circulation.

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A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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