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

Answer and Explanation

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.

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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.

A. "Although this is your first incident, we will have to terminate your employment." B. "We will review the incident report to determine the cause of the missed medication." C. "I will need to report this incident to the state board of nursing." D. "The facility's legal team will be contacting you to discuss the incident."

Correct Answer is B

Explanation

A. "Although this is your first incident, we will have to terminate your employment." This response is punitive and does not align with a just culture, which seeks to identify the cause of errors rather than immediately disciplining staff.
B. "We will review the incident report to determine the cause of the missed medication." This aligns with just culture principles by focusing on finding the root cause (e.g., workload issues, system inefficiencies) rather than blaming the nurse.
C. "I will need to report this incident to the state board of nursing." A missed medication dose that caused no harm typically does not require reporting to the state board. Just culture focuses on improving processes rather than unnecessary punishment.
D. "The facility's legal team will be contacting you to discuss the incident." Involving legal action for a minor, non-harmful event is excessive and contradicts just culture, which emphasizes education, accountability, and system improvements over legal consequences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse has initiated an incident report for a missed dose of medication on a client that caused no harm to the client. Which of the following responses by the nurse manager indicates the use of just culture?

Correct Answer is B

Explanation

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