A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield?
Suctioning a client's tracheostomy tube
Emptying an indwelling urinary catheter bag
Inserting an IV catheter for a client who has peritonitis
Changing the brief of an older adult client who has a Clostridium difficile infection
The Correct Answer is A
A. Suctioning a client's tracheostomy tube A face shield or goggles with a mask should be worn when performing procedures that generate aerosols or splashes, such as suctioning a tracheostomy. This helps protect the nurse from exposure to respiratory secretions.
B. Emptying an indwelling urinary catheter bag This task carries a low risk of splashing, so gloves are typically sufficient. If splashing is anticipated, wearing a gown and goggles may be appropriate.
C. Inserting an IV catheter for a client who has peritonitis IV insertion does not pose a high risk of splashes or sprays, so standard precautions (gloves) are usually adequate.
D. Changing the brief of an older adult client who has a Clostridium difficile infection While contact precautions (gown and gloves) are required for C. difficile, a face shield is not necessary unless significant splashing of fecal matter is expected. Hand hygiene with soap and water (not alcohol-based hand sanitizer) is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Consider gender and age when selecting an interpreter Cultural preferences may influence comfort and communication. For example, a client may feel more comfortable speaking with an interpreter of the same gender or age group.
B. Direct comments and questions to the interpreter The nurse should speak directly to the client, not the interpreter, to maintain engagement and respect.
C. Speak to the client in a loud voice Speaking louder does not improve comprehension and may come off as disrespectful. Clear, slow speech is more effective.
D. Ask a member of the client's family to serve as an interpreter Family members may omit or alter information and are not trained in medical terminology or confidentiality laws. A professional medical interpreter should be used.
Correct Answer is C
Explanation
A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.
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