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The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

Don gloves.

Apply a surgical mask.

Put on an isolation gown.

Wash hands.

Answer and Explanation

The Correct Answer is D,C,B,A

Correct order: D C B A

Washing hands is the first step before any PPE is applied to ensure cleanliness and prevent the introduction of pathogens.
Putting on the isolation gown is the next step, as it protects the nurse's clothing from exposure to potentially infectious materials.
Applying a surgical mask is the next step to protect the nurse from airborne or droplet transmission.
Donning gloves is the final step, as gloves should be put on last to protect the hands while providing direct care, especially when dealing with wound care.

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Correct Answer is B

Explanation

A. Call the nearest relative to come in and sign a new form is not the correct course of action. While family involvement may be important, the priority is to address the error in the consent form before proceeding with the surgery. The healthcare provider must be informed to ensure the correct procedure is performed.

B. Call the healthcare provider (HCP) to have the procedure rescheduled is the most appropriate action. The error in the consent form and the discrepancy between the consent and the surgical site marking must be addressed immediately to prevent a potentially catastrophic mistake. The healthcare provider will need to correct the error and ensure proper documentation before proceeding with surgery.

C. Have the client sign another form before surgery is not appropriate because the client has already been administered opioid medication, which may impair their ability to make informed decisions. The error in the consent form must be resolved with the healthcare provider before the client signs anything.

D. Cross out the error and initial the consent form is not an appropriate action. This could be seen as tampering with the document, and it does not resolve the issue of the incorrect surgical site. A new consent form must be signed after the error is corrected.

A. Prescription for ceftriaxone PO every 12 hours. B. A 26-year-old client. C. Blood pressure is 80/48 mm Hg. D. Admitted after a motor vehicle collision.

Correct Answer is C

Explanation

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

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The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Correct Answer is C

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

The healthcare provider prescribes streptomycin 200 mg intramusculary every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL". How many milliliters should the nurse administer? (Enter numerical value only. (If rounding is required, round to the nearest tenth.)

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?