A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Instilling an ophthalmic ointment for a client who has a corneal abrasion

Inserting an NG tube for a client who needs continuous enteral feedings

Changing a central venous catheter dressing for a client who is receiving IV therapy

Administering an IM injection to a client who has bacterial pneumonia

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Changing a central venous catheter dressing for a client who is receiving IV therapy. Choice A rationale: Instilling ophthalmic ointment typically does not require sterile gloves. Clean technique is sufficient as long as proper hand hygiene is performed to prevent infection. Choice B rationale: Inserting an NG tube requires clean technique, not sterile. The procedure is performed through the nasal passage and esophagus, which are not sterile environments. Choice C rationale: Changing a central venous catheter dressing requires sterile gloves to prevent introducing infection into the bloodstream. Central lines are a direct pathway to the central circulation, making aseptic technique critical to prevent serious infections such as bloodstream infections. Choice D rationale: Administering an IM injection requires clean technique. The skin is cleaned with an antiseptic wipe before the injection, but sterile gloves are not necessary for this procedure.

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Correct Answer is C

Explanation

Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves.

The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist.

The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.

A. "Let's take a walk outside to see if the voices you are hearing will stop." B. "Can you listen to me instead of the voices you are hearing?" C. "Are the voices you are hearing telling you to hurt yourself or someone else?" D. "I know that the voices are real to you, but I do not hear them."

Correct Answer is C

Explanation

The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.

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A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

Correct Answer is C

Explanation

A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

Correct Answer is C

Explanation

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