The nurse is caring for hospitalized clients. Which nursing action requires the nurse to use sterile gloves?

Administration of an enema

Administration of an intramuscular injection

Insertion of a nasogastric tube

Insertion of an indwelling catheter

Answer and Explanation

The Correct Answer is D

D. Inserting an indwelling catheter involves placing a tube into the bladder through the urethra. The urethra and urinary tract are sterile areas. Sterile gloves are necessary to prevent introducing pathogens into the urinary tract during catheter insertion.

A. An enema involves introducing a solution into the rectum for therapeutic purposes. It does not require the use of sterile gloves because the rectum and lower gastrointestinal tract are not considered sterile areas.

B. Administering an intramuscular injection involves injecting medication into muscle tissue. It does not require sterile gloves unless the site needs to be cleaned with an antiseptic wipe, in which case non- sterile gloves are sufficient.

C. The insertion of a nasogastric tube also does not typically require sterile gloves, as the gastrointestinal tract is not a sterile environment.

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Correct Answer is B

Explanation

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

A. defecate regularly. B. increase ingestion of fruits. C. limit fluid intake. D. regain normal stool consistency.

Correct Answer is D

Explanation

D. This is the most appropriate goal for a client experiencing diarrhea. Diarrhea is characterized by loose or watery stools, and the goal of treatment is to restore normal stool consistency. This goal focuses on improving the symptoms and resolving the underlying cause of diarrhea, whether it's due to infection, dietary factors, or other reasons.

A. "Defecating regularly" does not necessarily imply improvement in diarrhea symptoms or resolution of the underlying cause. It is vague and does not provide a clear target related to diarrhea management.

B. Increasing ingestion of fruits may be beneficial for some individuals as fruits contain fiber and fluids that can help regulate bowel movements and maintain hydration. However, certain fruits high in fiber (e.g., apples, pears) may exacerbate diarrhea in some cases. This goal should be tailored based on the individual's tolerance and specific dietary needs.

C. This goal is not appropriate for managing diarrhea. Diarrhea leads to fluid loss and dehydration, so limiting fluid intake can worsen dehydration and electrolyte imbalances. Adequate fluid intake is crucial to replace lost fluids and maintain hydration during episodes of diarrhea.

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The nurse is caring for hospitalized clients. Which nursing action requires the nurse to use sterile gloves?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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