1. D. The organism’s mode of transmission

Rationale: Identifying the mode of transmission helps the nurse select the appropriate isolation precaution to institute. For example, if the organism is transmissible through skin-to-skin contact, then the nurse enforces contact precautions. Identifying Gram-staining characteristics and the organism’s susceptibility to antibiotics are important considerations for the development of drug therapy and an effective care plan. The client’s susceptibility to the organism was already proven through the contraction of the disease.

  1. B. Pulling the gloves gently inside-out just below the cuff.

Rationale: In removing contaminated gloves, turning them inside-out while pulling them off keeps potentially infectious pathogens inside the gloves. These are then discarded with the other articles of contaminated PPE into the infectious garbage pail. The gloves are grasped at the outer side of the wrist part, not the fingers, to follow the principle of infectious-to-infectious and clean-to-clean. Washing the gloves is inappropriate because these are single-use items only. Pulling the gloves without turning them inside-out already will require the nurse to touch the contaminated part with the ungloved hand, therefore contaminating it.

  1. C. The equipment is penetrated better with the pressurized steam.

Rationale: The items are exposed to direct steam at the required temperature and pressure for the specified time. The moist heat is rapidly microbicidal and sporicidal, and rapidly heats and penetrates fabrics. The autoclave must never be overloaded so that there is sufficient room for steam circulation, and items inside must never touch the interior walls to avoid the melting of plastics. Specific temperatures of 121°C (250°F) or 132°C (270°F) must be obtained to ensure microbicidal activity. Like all sterilization processes, the use of an autoclave has some deleterious effects on some materials, including corrosion and combustion of lubricants with dental pieces and increased hardening time with a plaster cast.

  1. B. Wear a clean gown and gloves when caring for the client.

Rationale: Methicillin-resistant Staphylococcus aureus (MRSA) infection is spread through direct contact with the client, their immediate surroundings, and objects in their contact, therefore, contact precautions must be instituted. This requires wearing of gown and gloves before entering the client’s room. Whenever possible, clients diagnosed with MRSA will have a single room or will share a room only with someone else who also has MRSA. An N95 respirator mask is only required with airborne precautions. Before leaving the client’s room, all gowns and gloves are removed and the hands are disinfected. All linens and trash from the client’s room must be clearly marked infectious and double bagged.

  1. A. A client diagnosed with unstable diabetes mellitus

Rationale: Protective isolation aims to protect an immunocompromised client who is at high risk of acquiring pathogens from either the environment or from other clients, staff, or visitors. The client diagnosed with unstable diabetes mellitus can be safely paired with the client in protective isolation because there is no current infection to be concerned about. The client diagnosed with a urinary tract infection could potentially cause an endogenous infection (an infection caused by a pathogen that has remained dormant inside the body) in the immunocompromised client. A perforated bowel exposes the client to infections that require antibiotic therapy during the postoperative period. The client with open wounds such as a stage 3 pressure injury is not to be paired with the immunocompromised client because infectious microorganisms may be present in an open wound.

  1. B. Observe the client’s vomitus.

Rationale: The nurse observes and documents the characteristics of the vomitus, noting its color, consistency, and amount. Nausea and vomiting are common adverse effects of codeine that are expected to diminish within days or weeks of codeine exposure. The nurse may then notify the health care provider of the vomiting episode so that the provider could decide whether to readminister the dose or not. Telling the client that nothing can help anymore is non-therapeutic. Instead, the nurse may educate the client regarding the drug’s onset of action and its adverse effects.

  1. C. Assess the symptomatic quadrant last.

Rationale: The assessment must begin with superficial or light palpation from the area furthest from the point of maximal pain and must move systematically through the quadrants of the abdomen. If no pain is present, then any starting point can be chosen. Starting from the painful quadrant will elicit a guarding behavior from the client, which is either a voluntary process wherein the abdominal muscles are tightened to protect a deeper inflamed structure or an involuntary process where the intra-abdominal pathology has progressed to cause rigidity of the abdominal muscles.

  1. B. “The client has a low pain threshold.”

Rationale: The pain threshold is the minimum point at which something, such as pressure or heat, causes pain. Pain threshold and tolerance vary from person to person, therefore, the nurse cannot say that the client is faking the pain. Both may depend on complex interactions between the nerves and the brain. Pain is a subjective experience and many elements may influence it. The pain was real to the client, and pain medication may be needed once the client wakes up.

  1. B. “A warm compress can increase the blood circulation.”

Rationale: Using a warm compress improves the circulation of the blood, which helps eliminates the build-up of chemicals such as lactic acid that causes soreness and pain in muscles. Cold compresses can also help reduce pain and discomfort by causing numbness in the affected area and relaxing the muscles, thereby reducing muscle spasms. A warm compress does not prevent a hemorrhage, rather, it promotes vasodilation which promotes hemorrhage.

  1. C. Pain description

Rationale: Subjective data are information from the client’s point of view, which includes the client’s feelings, perceptions, and concerns obtained through interviews. This includes the client’s description of pain. Objective data, such as laboratory results, vital signs, and ECG patterns are obtained through observation, physical examination, and laboratory or diagnostic testing.

  1. C. The client’s apical pulse

Rationale: The apical pulse, which is the pulse at the apex of the heart, can be located at the midclavicular line in the fourth, fifth, or sixth intercostal space. It can be elicited through palpation and is rarely used when taking baseline vital signs. Baseline vital signs include temperature, pulse rate (radial pulse is the most common site for assessment), respiratory rate, and blood pressure. All of these cannot be assessed through palpation of the midclavicular line.

  1. A. The client stands with both feet together.

Rationale: In the Romberg test, the client is asked to remove their shoes and then stand with both feet together. Then, the client is asked to hold their arms next to the body or cross in front of the body. Sitting, having the arms stretched forward, and assuming the Trendelenburg position is not involved with the Romberg test. The Romberg test identifies specific neurologic impairments such as ataxia or severe incoordination.

  1. D. The diaphragm can detect high-pitched sounds best.

Rationale: The stethoscope’s bell is flat and round and is covered by a thin layer of plastic known as the diaphragm. The diaphragm vibrates as sound is produced within the body, allowing it to detect high-pitched sounds best. The bell detects low-pitched sounds best, while palpation allows the nurse to assess for thrills.

  1. C. The nurse auscultates the abdomen first, then performs percussion, and finally, palpates the abdomen.

Rationale: Abdominal examination could start with auscultation. Starting with palpation and percussion can affect bowel motility and bowel sounds and would render the assessment unreliable. Tympanic percussion, measurement of the abdominal girth, and assessing for tenderness, distention, and discoloration are all appropriate techniques in an abdominal examination, but these should come after auscultation.

  1. A. A weak, rapid pulse

Rationale: An older adult who has not eaten or had anything to drink could manifest signs of dehydration, which includes a weak and rapid pulse. Older adults are more susceptible to fluid volume deficit because of age-related changes in total body water, thirst perception, renal concentrating ability, and vasopressin effectiveness that could lead to a higher risk of dehydration. All the other options are signs of fluid volume excess.

  1. C. Ask the client to perform the administration of ear medication.

Rationale: Letting the client perform or return-demonstrate the instillation of ear medication as the nurse observes is the best way to gauge if the client understood the discharge teaching. Instructions are remembered more effectively when the client puts the words into action. Memorizing the instructions and repeating them verbally does not guarantee that the client understood the instructions. Performing the action while the client is asking questions may distract both the nurse and the client from the appropriate technique. Questions and concerns are entertained at the end of the demonstration. Merely asking the client if they had used an ear medication before does not ensure that the client knows how to instill it properly.

  1. C. Withhold the medication and notify the health care provider.

Rationale: Hypersensitivity reactions to penicillin includes urticaria and pruritus or rash with an immediate onset within 20 minutes post-administration. To avoid an anaphylactic shock, the nurse must withhold the medication and then inform the healthcare provider. The healthcare provider may decide to change the medication altogether. The administration of the medication again could predispose the client to anaphylactic shock. Applying cornstarch soaks may relieve the skin rash, but it does not eliminate the client’s potential allergic reaction to penicillin. The nurse cannot administer an antihistamine without the healthcare provider’s orders first.

  1. A. Administers the medication using the Z-track method.

Rationale: The Z-track method of injection prevents the leakage of irritating and discoloring medications such as iron dextran into the subcutaneous tissue. It is also used in older adult clients who have decreased muscle mass. When preparing to give medication using this method, the needle must be long enough to reach the muscle. Never massage the injected area because it could force the medication into the subcutaneous tissue. Injecting the medication at a 45-degree angle into an older adult client (who may have very little subcutaneous fat) delivers it into the subcutaneous area.

  1. D. Check if a liquid preparation is available at the pharmacy.

Rationale: The nurse should check first if the medication is available in a liquid form at the hospital’s pharmacy and inform the healthcare provider of the client’s difficulty in ingesting the drug. Swallowing a capsule can be difficult because they are lighter than water and float due to the air trapped inside the gelatinous shell. Mixing the contents of the capsule with applesauce or dissolving it in a glass of water may alter the effectiveness of the medication. Placing the medication contents under the tongue is not the appropriate way of administering oral medication and can harm the client’s oral mucosa.

  1. C. Ask the client to provide their last and first name.

Rationale: Identifying the correct client to whom the medication is prescribed belongs to the nursing rights of medication administration under the “right client’. To best identify the client, the nurse should ask them to provide their full name aloud, then check the client’s identification band and the ID number on the client’s chart if they match. It is not advisable to address or call out the client by their surname, in the event that more than one client has the same name in the unit. In some cases, like in psychiatric clients, there are no identification bands or a bed tag with their name on it, or they may have altered mental status and therefore are unable to identify themselves correctly.

  1. B. Side rails add stability and guidance for the weak client.

Rationale: Side rails or bed rails do not prevent the risk of falling completely; they are active reminders that may guide and provide stability for the client when moving in bed, especially when they have mobility issues or are physically weak. They should not be prohibited from inpatient beds because beds without side rails could let a client roll off when asleep or when changing positions. They are not deterrents to the prevention of falls, rather, they can decrease the risk of falls with proper installation and use. Mobile clients can use side rails effectively by using them as support when changing positions or getting out of bed.

  1. B. “The restraints discourage the client from ambulating alone.”

Rationale: Restraints should be used as the last resort in dealing with confused, agitated, violent, or disoriented clients. In the event of preventing a disoriented client from ambulating without assistance, a soft wrist restraint can be used, provided that the family members were informed and signed a consent form and that the nurse closely monitors and documents the use of restraints. The restraint will not help in decreasing the client’s confusion. Restraints can sometimes even cause injury to the client, such as pressure injuries, skin breakdown, abrasions, asphyxia, or depression, if not monitored appropriately. A violent client must be calmed down first before considering any use of restraints right away.

  1. B. Cool, pale fingers

Rationale: A soft wrist restraint may impair blood circulation when it is tied tightly or if it does not allow for any sort of movement for the wrist and hands. Cool, pale fingers are a sign of restricted blood supply to the extremities. The nurse must routinely assess and document findings in a client with restraint. A capillary refill of two seconds, warm and reddened palms, and pinkish nail beds are signs of good blood circulation. These are the findings that should be regularly assessed and documented by the nurse.

  1. C. Let the client dangle their legs at the side of the bed.

Rationale: If the client is able, assist them into a sitting position on the bed first and dangle their legs at the side to prevent an episode of orthostatic hypotension. Lowering the bed into a flat position will require a lot of strength from the client to get off the bed; instead, raise the head of the bed to an angle that the client can tolerate, then lower the bed itself to a safe working height. The chair should be facing the client and next to the bed at a 45-degree angle. Do not lift the client rapidly from the bed because this could cause orthostatic hypotension or the client can become injured from being off-balance.

  1. B. Elevating the head of the bed prior to feeding

Rationale: Elevating the head of the bed before starting an enteral feeding will decrease the risk of aspiration. Aspiration is more common when clients are fed via a nasogastric tube in a supine position. Continuous feeding formulas should not be warmed in a microwave or in boiling water. They should be given at room temperature to minimize gastrointestinal distress. If the client cannot tolerate a sitting position or the elevation of the head of the bed, the nurse may turn them to a right side-lying position to allow the tip of the tube to a position where fluid has accumulated. Continuous feeding formulas are not hung for longer than four hours because this could invite the growth of harmful pathogens in the formula.

  1. B. Cleaning in a circular motion from the center outward.

Rationale: A Jackson-Pratt drain is used to empty excess fluid from the body after surgery. The area around the wound drain should be cleaned starting from the center and going outward in large, circular motions because the skin around the site is more contaminated than the site itself. The use of alcohol is avoided because it may irritate the skin. Soap and water are sufficient when cleaning the skin around the drain. Only sterile gloves are necessary when providing care for a surgical drain. A gown can be used in anticipation of body fluids that may leak when removing the drain. The drain can only be removed as advised by the healthcare provider.

  1. D. Include fruits like bananas and oranges in the diet.

Rationale: Furosemide is a potassium-wasting diuretic, therefore, the nurse encourages the client to consume more potassium-rich foods such as oranges and bananas to prevent the development of hypokalemia. Intake of foods rich in protein, fiber, and green, leafy vegetables is also beneficial for the client but does not affect the potassium levels significantly.

  1. B. Hydrocolloid dressing

Rationale: If the wound has healthy granulation tissue and needs to have faster healing and epithelialization, a hydrocolloid dressing can help. An occlusive semiocclusive dressing is more appropriate in a superficial wound. The dry dressing is indicated for soiled abrasions, punctured wounds, or sutured dry lacerations. Plastic-film dressings are known to absorb exudate and are used for wounds with a moderate amount of exudate. They should not be used in dry wounds.

  1. C. Side-lying position

Rationale: A client who underwent a tonsillectomy and is lethargic is at high risk of aspiration, therefore, the nurse must place the client in a side-lying position to facilitate effective drainage of the blood. A sore throat is an expected effect after tonsillectomy, but bleeding is a common and feared complication. Placing the client in a high-Fowler’s, semi-Fowler’s, or supine position increases the risk of aspiration from the client’s blood.

  1. C. Sim’s position

Rationale: The Sim’s position is typically used to examine the rectal area, however, in the client’s case, it should be avoided because of the history of hip replacement surgery. The hip joint could be injured if the client assumes a Sim’s position because it requires flexion of the hips and knees. The client may assume the dorsal recumbent, semi-Fowler’s, and supine position without injuring the hip joint.

References

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  3. Britto, E. J., Nezwek, T. A., & Robins, M. (2022, June 5). Wound Dressings – StatPearls. NCBI. Retrieved August 10, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK470199/
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Marianne Belleza has been a registered nurse for seven years and has worked as an outpatient department and emergency department nurse in the Philippines for over three years. Her career as a nurse writer began nearly eight years ago. Since then, she has worked on feature stories and nursing care plans. She began creating NCLEX review questions more than a year ago and is now working on Next-Generation NCLEX. She also passed the B2 Telc Exam for Nurses and hopes to work as a nurse in Germany later this year.

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