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 D

Explanation

A. "I should close all doors and windows on the unit." –
This action is part of the "C" (Confine) step, which should be done before attempting to extinguish the fire.
B. "I should evacuate clients who are in immediate danger." –
Rescuing clients is the first step and should be done immediately.
C. "I should activate the facility's fire alarm system." –
Activating the alarm is the second step after rescuing clients.
D. "I should extinguish small fires if it is safe to do so." –
Extinguishing the fire is the last action in the fire safety protocol and should only be attempted if the fire is small and controllable.

A. Insert the IV catheter using the Z-track technique. B. Insert the IV catheter with the bevel down. C. Remove the roller clamp from the tubing prior to IV insertion. D. Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site.

Correct Answer is D

Explanation

A. "Insert the IV catheter using the Z-track technique." The Z-track technique is used for intramuscular (IM) injections, not IV therapy.
B. "Insert the IV catheter with the bevel down." The bevel should be up to facilitate smooth vein entry.
C. "Remove the roller clamp from the tubing prior to IV insertion." The roller clamp should remain in place to control fluid flow and prevent air from entering the tubing.
D. "Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site." This placement helps distend the vein for easier cannulation without restricting arterial blood flow.

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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

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