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. Prime the IV tubing with lactated Ringer's. Blood products should only be primed with 0.9% sodium chloride (normal saline) because other solutions (e.g., lactated Ringer's or dextrose solutions) can cause hemolysis.
B. Use a 24-gauge IV catheter for the transfusion. A 24-gauge catheter is too small for a blood transfusion and may cause hemolysis or slow infusion. A large-bore catheter (18–20 gauge) is recommended for optimal flow.
C. Ensure that the IV tubing has an in-line filter. An in-line filter helps remove clots and debris, reducing the risk of transfusion reactions.
D. Prepare to change the tubing at least every 2 hr. Blood tubing should typically be changed after 4 hours or after two units of blood, whichever comes first, to prevent bacterial contamination.

A. "Do you have difficulty sleeping at night?" B. "How do you feel about the current status of your life?" C. "Have you noticed changes in your eating patterns?" D. "Are you comfortable discussing the disaster with your family or friends?"

Correct Answer is D

Explanation

A. "Do you have difficulty sleeping at night?" – While sleep disturbances are common in PTSD, this question assesses symptoms rather than support systems.
B. "How do you feel about the current status of your life?" – This question may provide insight into the client’s emotional state but does not directly assess their support systems.
C. "Have you noticed changes in your eating patterns?" – Changes in appetite can occur with PTSD, but this question focuses on physical symptoms rather than support systems.
D. "Are you comfortable discussing the disaster with your family or friends?" – This is the best choice because it directly assesses whether the client has a support system in place and feels comfortable relying on them for emotional support.

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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

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Explanation

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Correct Answer is D

Explanation

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