When donning sterile gloves, how should the second glove be handled?
1
Grasp by cuff and place on remaining hand.
2
Place sterile glove under cuff, and slide hand in glove.
3
Grasp inside second glove and place on nondominant hand.
4
Don glove on nondominant hand first, then hold below waist and slide on. -
ANS ✓2
Sterile gloves can only be handled by sterile equipment, or they are
contaminated. The sterile glove that has been donned may touch under the
cuff on the sterile surface as the nondominant hand is inserted. The sterile
glove may not touch the inside of the glove. Donning a sterile glove and
placing below the waist means contamination, as under the waist or in back
is contaminated. Grasping by the cuff means the inside of the glove has
been touched.
A hospice nurse is caring for a dying client while several family members
are in the room. When the client dies, the initial nursing intervention
during the shock phase of a grief reaction is focused on what?
1
Staying with the individuals involved
2
Directing the individual's' activities at this time
3
Mobilizing the support systems of the individuals
4
Presenting the full reality of the loss to the individuals - ANS ✓1
Staying with the individuals involved provides support until the
individuals' coping mechanisms and personal support systems can be
mobilized. Directing the individuals' activities at this time is not the role of
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the nurse. The individuals, not the nurse, must mobilize their support
systems. The individuals need time before the full reality of the loss can be
accepted.
A dehydrated 2-month-old infant with a history of diarrhea is admitted to
the pediatric unit. Oral rehydration therapy is instituted. What is the most
accurate method of monitoring the infant's hydration status?
1
Counting wet diapers
2
Obtaining daily weights
3
Measuring intake and output
4
Checking tissue turgor of the abdomen - ANS ✓2
Daily weighing provides an objective measurement, because a weight loss
indicates a loss of fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid.
Although a wet diaper count is an objective measure, it is necessary to
weigh the diapers before and after the infant voids to estimate the amount
of fluid loss. Intake can be measured accurately; however, output,
especially with diarrhea, is difficult to measure. Tissue turgor is a
subjective assessment, open to a variety of interpretations. Also, the site
that should be assessed is over the sternum, not the abdomen.
A nurse is assessing a client with a diagnosis of primary insomnia. Which
findings from the client's history may be the cause of this disorder? Select
all that apply.
1
Chronic stress
2
Severe anxiety
3
Generalized pain
4
Excessive caffeine
5
Chronic depression
6
Environmental noise/distractors - ANS ✓1,4,6
Acute or primary insomnia is caused by emotional or physical stress not
related to the direct physiologic effects of a substance or illness. Excessive
caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant
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that inhibits sleep. Environmental noise causes physical and emotional
discomfort and is therefore related to primary insomnia. Severe anxiety is
usually related to a psychiatric disorder and therefore causes secondary
insomnia. Generalized pain is usually related to a medical or neurologic
problem and therefore causes secondary insomnia. Chronic depression is
usually related to a psychiatric disorder and therefore causes secondary
insomnia.
A client who had a cerebrovascular accident (also known as a "brain
attack") becomes incontinent of feces. What is the most important nursing
action to support the success of a bowel training program?
1
Using medication to induce elimination
2
Adhering to a definite time for attempted evacuations
3
Considering previous habits associated with defecation
4
Timing of elimination to take advantage of the gastrocolic reflex - ANS ✓2
Bowel training is a program for the development of a conditioned reflex
that controls regular emptying of the bowel. The key to success is
adherence to a strict time for evacuation based on the client's individual
schedule. The indiscriminate use of laxatives can result in dependency.
Although previous habits should be considered, the brain attack affects the
responses of the client by altering motility, peristalsis, and sphincter
control despite adherence to previous habits. The passage of food into the
stomach does stimulate peristalsis, but it is only one factor that should be
considered when planning a specific time for evacuation.
The nurse is teaching a parent of a 2-year-old toddler how to administer
ear drops. In what direction does the nurse teach the parent to gently pull
the pinna?
1
Forward
2
Up and back
3
Straight back
4
Down and back - ANS ✓4
In children younger than 3 years of age the eustachian tube is shorter,
wider, and more horizontal. Pulling the pinna down and back facilitates
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