The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Washes hands before handling the needle and syringe.

Wears gloves to dispose of the needle and syringe.

Dons a face mask before administering the medication.

Removes the needle before discarding used syringes.

Answer and Explanation

The Correct Answer is A

Choice A reason: Hand hygiene is the foundation of Standard Precautions and the single most effective action to prevent transmission of infectious agents. Performing handwashing or using an alcohol‑based hand rub immediately before preparing or administering an injection removes transient microorganisms acquired from touching surfaces and protects both the client and the environment from contamination

Choice B reason: While wearing gloves during handling and disposal of contaminated sharps is recommended whenever there is potential contact with blood or body fluids, it is a secondary barrier. Reliance on gloves alone is insufficient because gloves can have micro‑perforations and are removed after use, making hand hygiene before and after glove use the priority

Choice C reason: Donning a face mask before administering the medication is not a necessary action to indicate an understanding of standard precautions. A face mask is only required when there is a risk of droplet transmission of infectious agents, such as when caring for a client with respiratory infections. It is not needed for self-administration of medications, unless the medication is aerosolized or nebulized.

Choice D reason: Removing the needle before discarding used syringes is not a safe action to indicate an understanding of standard precautions. It increases the risk of needle-stick injuries and contamination. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action because the nurse should provide realistic expectations and positive reinforcement to the client. Lifestyle changes such as exercise can improve sleep quality and duration, but they may not have immediate effects. The nurse should encourage the client to continue the workout program and follow good sleep hygiene practices.

Choice B reason: This is not the best action because the nurse should focus on the client's sleep problem rather than the weight loss goal. While weight loss can be a benefit of exercise, it is not the primary reason why the client started the workout program. The nurse should not make the client feel that weight loss is the only measure of success.

Choice C reason: This is also not the best action because the nurse should not interrogate the client about the details of the exercise schedule. The nurse should respect the client's autonomy and preferences regarding physical activity. The nurse can offer suggestions or resources to help the client optimize the exercise schedule, but should not imply that the client is doing something wrong.

Choice D reason: This is another incorrect action because the nurse should not encourage the client to exercise every day or close to bedtime. Exercising too frequently or too late can interfere with the body's circadian rhythm and cause sleep problems. The nurse should advise the client to exercise at least three times a week and avoid exercising within three hours of bedtime.

A. Apply the client's positive airway pressure device. B. Lift and lock the side rails in place. C. Remove dentures, or other oral appliances. D. Elevate the head of the bed to a 45-degree angle.

Correct Answer is A

Explanation

Choice A reason: Applying the client's positive airway pressure device is the most important intervention for the nurse to implement before leaving the client. It helps to prevent the collapse of the upper airway and maintain adequate ventilation and oxygenation. It also reduces the risk of respiratory depression and apnea that may be caused by the opioid analgesic.

Choice B reason: Lifting and locking the side rails in place is a safety measure for the nurse to implement before leaving the client, but not the most important one. It helps to prevent the client from falling or injuring themselves, but it does not address the client's respiratory status or the effect of the medication.

Choice C reason: Removing dentures, or other oral appliances is a comfort measure for the nurse to implement before leaving the client, but not the most important one. It helps to prevent the client from choking or aspirating on the foreign objects, but it does not improve the client's airway patency or ventilation.

Choice D reason: Elevating the head of the bed to a 45-degree angle is a supportive measure for the nurse to implement before leaving the client, but not the most important one. It helps to facilitate the client's breathing and drainage of secretions, but it does not prevent the obstruction of the airway or the respiratory depression that may occur with the opioid analgesic.

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The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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