Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?- Skildor

Question 1 of 5

Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct Answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

Question 2 of 5

UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?

A. A feeding is infusing at 40 mL/hr through an enteral feeding tube B. The urine meter attached to the urinary drainage bag is completely full C. There is a large dependent loop in the client's urinary drainage tubing D. Purulent drainage is present around the insertion site of the feeding tube

Correct Answer: D

Rationale: Purulent drainage indicates infection at the insertion site, which requires immediate attention to prevent complications.

Question 3 of 5

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct Answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

Question 4 of 5

A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

A. The client's blood pressure is 130/80 mm Hg. B. The client gains 1 kg in 24 hours. C. The client's potassium level is 5.5 mEq/L. D. The client's weight decreases by 0.5 kg in 24 hours.

Correct Answer: C

Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.

Question 5 of 5

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

A. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically D. Completing the electronic record during an interview is a legal obligation of the examining nurse

Correct Answer: C

Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.

HESI Fundamentals

Skildor

HESI RN

HESI RN

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