Nclex Review Foundations

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure? 1. Half-inch tape 2. Oil-soluble lubricant 3. A 50-mL catheter tip syringe 4. A glass of tap water with a straw

Oil-soluble lubricant

The health care provider's prescription reads levothyroxine, 100 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client?

1 tablet

A health care provider prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute?

10gtt/min

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq of KCl per 15 mL. The nurse should prepare how many milliliters of KCl to administer the correct dose of medication?

11ml

A health care provider prescribes heparin sodium 900 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin 25,000 units in 500 mL of normal saline. An infusion pump must be used to administer the medication. How many milliliters per hour are required to deliver the prescribed dose?

18ml/hour

The health care provider prescribes digoxin 0.25 mg orally daily for a client with heart failure. The medication label states 0.125 mg per tablet. The nurse should administer how many tablet(s) to the client?

2 tablets

The prescription for an infusion of parenteral nutrition reads: Infuse 1800 mL bag over 24 hours. At what rate will the nurse set the infusion pump?

75ml/hour

The nurse is providing discharge dietary teaching to a client with a history of irritable bowel syndrome (IBS). What comment made by the client tells the nurse that further instruction is needed? 1. "I'll eat more beans and peas." 2. "I should eliminate caffeine and alcohol." 3. "I'm afraid my son will get this disease." 4. "I know I need to take vitamins and mineral supplements."

"I'll eat more beans and peas." Rationale: IBS clients have problems with excess gas formation, with increased distention and bloating that is accompanied by rumbling abdominal sounds, belching, and flatulence, so legumes such as beans and peas should be avoided. Caffeine and alcohol also have to be eliminated. IBS can be inherited. Vitamins and mineral supplements are generally included in the dietary regime.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Which statement should the nurse make to the client before removing the tube? 1. "Take a deep breath when I tell you, and hold it while I remove the tube." 2. "Take a deep breath when I tell you, and bear down while I remove the tube." 3. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." 4. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

"Take a deep breath when I tell you, and hold it while I remove the tube." Rationale: The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath while the tube is removed. The nurse should remove the tube slowly and evenly over the course of 3 to 6 seconds. Bearing down could inhibit the removal of the tube. Exhaling and breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape?

375ml Rationale: If the IV is scheduled to run over 8 hours, the hourly rate is 125 mL/hour. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500.

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

Arrange for an interpreter to translate. Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed? 1. Ask the client to void, save the specimen, and note the start time. 2. Place the specimen in various containers as necessary for the test. 3. Ask the client to save a sample voided at the end of the collection time. 4. Remove urine from the collection container for other prescribed specimens.

Ask the client to save a sample voided at the end of the collection time. Rationale: Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder; therefore, the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine sample should be placed in the appropriate container and may be refrigerated or placed on ice to prevent changes in the urine. Because this is a quantitative determination of constituents in the urine, no urine should be removed from the container.

The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube? 1. Placing the NG tube in warm water 2. Hyperextending the head to insert the tube 3. Removing the tube if any resistance to insertion is met 4. Asking the client to swallow as the tube is being advanced

Asking the client to swallow as the tube is being advanced

A client's nasogastric feeding tube has become clogged. The nurse should take which action first? 1. Replace the tube. 2. Aspirate the tube. 3. Flush with carbonated liquids. 4. Flush the tube with warm water.

Aspirate the tube.

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action? 1. Assess tube placement. 2. Flush with 30 mL of sterile saline. 3. Aspirate to determine residual volume. 4. Administer the antacid by gravity flow.

Assess tube placement.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

Bed rest with elevation of the affected extremity Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply 1. Blood transfusions 2. Metabolic alkalosis 3. Bleeding or hemorrhage 4. Decreased sodium excretion 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium

Blood transfusions Bleeding or hemorrhage Ingestion of potassium in medications Failure to restrict dietary potassium Rationale: With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.

Which actions should the nurse include when caring for a client with continuous tube feedings through a nasogastric (NG) tube? Select all that apply. 1. Check the residual every 4 hours. 2. Check for placement every 4 hours. 3. Hang a new feeding bag every 72 hours. 4. Check skin integrity at the site of NG tube insertion. 5. Check for placement before administering medications

Check the residual every 4 hours. Check for placement every 4 hours. Check skin integrity at the site of NG tube insertion. Check for placement before administering medications. Rationale: A feeding bag and tubing should be changed every 24 hours (or per agency protocol) to reduce risk of bacterial contamination. Placement and residual should be checked at least every 4 hours during administration of continuous tube feedings and prior to giving medications through the tube. Agency policy for technique for assessment of tube placement should be followed. Skin integrity should be assessed at the site of NG tube insertion.

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. 1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Remove the tube and place it in the other nostril. 5. Test the stomach contents for a pH indicating acidity.

Check the residual volume. Aspirate the stomach contents. Turn off the suction to the nasogastric tube. Test the stomach contents for a pH indicating acidity.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper nasogastric tube placement 4. Checking for the presence of bowel sounds in all 4 quadrants

Checking for the presence of bowel sounds in all 4 quadrants

The nurse is providing instructions to a client with hypophosphatemia. Which food item should the nurse instruct the client to avoid? 1. Fish 2. Cheese 3. Chicken 4. Organ meats

Cheese Rationale: Diet therapy for hypophosphatemia consists primarily of an increased intake of phosphorus-rich foods while decreasing the intake of calcium-rich foods. Fish, chicken, and organ meats are food items that are allowed, whereas cheese should be avoided because it is a calcium-rich food.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? 1. Position the client supine to assist in medication absorption. 2. Aspirate the nasogastric tube after medication administration to maintain patency. 3. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. 4. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

Continue with the instructions, verifying client understanding. Rationale: Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading.

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1. Cream of wheat, blueberries, coffee 2. Sausage and eggs, banana, orange juice 3. Bacon, cantaloupe melon, tomato juice 4. Cured pork, grits, strawberries, orange juice

Cream of wheat, blueberries, coffee Rationale: The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which is indicated in the correct option. The food items in the remaining options are high in sodium, phosphorus, or potassium.

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? 1. Normal 2. Increased 3. Decreased 4. Insignificant

Decreased Rationale: The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.

A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply. 1. Dehydration 2. Catabolic state 3. High-protein diet 4. Fluid volume excess 5. Obstructive uropathy 6. Acute renal tubular acidosis

Dehydration Catabolic state High-protein diet Obstructive uropathy Rationale: Causes of an increased BUN to creatinine ratio include dehydration, a catabolic state, a high-protein diet, and obstructive uropathy. A decreased ratio is caused by fluid volume excess or acute renal tubular acidosis.

The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position? 1. Elevated above shoulder level 2. Elevated on one or two pillows 3. Level with the right-sided atrium 4. Dependent to the right-sided atrium

Elevated on one or two pillows Rationale: The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This promotes optimal drainage from the limb without impairing the circulation to the arm. If the arm is positioned flat (option 3) or dependent (option 4), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? 1. Ensure that a sterile safety pin is through the drain. 2. Measure the amount of drainage in a measuring container. 3. Establish that the drain is at the prescribed amount of suction. 4. Squeeze the suction device and close the port after emptying the drain.

Ensure that a sterile safety pin is through the drain.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. At which frequency should the nurse plan to check the IV sites of these clients? 1. Every hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours

Every hour Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV may be checked even more frequently, depending on whether medication also is being infused. The time periods in options 2, 3, and 4 are too infrequent. In addition, agency policy and procedures are always followed regarding care to an IV site.

The nurse has a prescription to obtain a 24-hour urine collection in a client with a renal disorder. Which actions should the nurse take when collecting this specimen? Select all that apply. 1. Explain the procedure to the client. 2. Save all subsequent voidings after the first void during the 24-hour period. 3. During the collection period, place the main container on ice or in a refrigerator. 4. Have the client void at the end time, and place this specimen in the main container. 5. Have the client void at the start time, and place this specimen in the main container.

Explain the procedure to the client. Save all subsequent voidings after the first void during the 24-hour period. During the collection period, place the main container on ice or in a refrigerator. Have the client void at the end time, and place this specimen in the main container. Rationale: The nurse should first explain the procedure to the client and ask the client to void at the beginning of the collection period and to discard this urine sample. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The client is asked to void at the finish time, and this sample is added to the collection. The container is labeled, placed on fresh ice, and sent to the laboratory immediately.

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding? 1. Supine 2. Flat on the left side 3. Fowler's on the right side 4. Semi Fowler's on the left side

Fowler's on the right side

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler's 3. High Fowler's 4. Supine with the head flat

High Fowler's

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem? 1. Infection 2. Malnutrition 3. Iron deficiency 4. Sickle cell disease

Iron Deficiency Rationale: Iron deficiency anemia usually is characterized by decreased iron-binding capacity and increased transferrin saturation. Infection is not associated with these laboratory values. Malnutrition can cause reductions in both iron-binding capacity and transferrin saturation. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the client's temperature. 2. Contact the health care provider. 3. Isolate the client in a private room. 4. Check a complete set of vital signs.

Isolate the client in a private room. Rationale: The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Liberia. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0°C (100.4°F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the health care provider and other state and local authorities of the client's signs and symptoms.

A client who has a serum potassium (K+) level of 2.9 mEq/L (2.9 mmol/L) tells the nurse that he does not feel like eating lunch. The nurse checks his serum digoxin level from that morning and notes that it is 1.0 ng/mL (1.2 nmol/L). What should the nurse determine about this digoxin level? 1. Low 2. Extremely toxic 3. Within the therapeutic range 4. Just above the high end of the therapeutic range

Just above the high end of the therapeutic range Rationale: Digoxin is a cardiac glycoside that is used to treat dysrhythmias such as atrial fibrillation in clients with heart failure. Digoxin blood levels need to be checked while the client is taking this medication to monitor for toxicity. The normal therapeutic range for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). Therefore, a blood level of 1.0 ng/mL (1.2 nmol/L) is just above the high end of the therapeutic range. It is important to be aware that a low K+ level has an additive effect in increasing the risk of digoxin toxicity. The normal K+ level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

Which clients have a high risk of obesity and diabetes mellitus? Select all that apply. 1. Latino American man 2. Native American man 3. Asian American woman 4. Hispanic American man 5. African American woman

Latino American man Native American man Hispanic American man African American woman Rationale: Because of their health and dietary practices, Latino Americans, Native Americans, Hispanic Americans, and African Americans have a high risk of obesity and diabetes mellitus. Owing to dietary practices, Asian Americans have a lower risk for obesity and diabetes mellitus.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left Sims' position 2. Right Sims' position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees

Left Sims' position

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow

Percussion and vibration

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? 1. Mark the tube at 10 inches (25.5 cm). 2. Mark the tube at 32 inches (81 cm). 3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. 4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? 1. Insert the tube quickly. 2. Notify the health care provider immediately. 3. Remove the tube and reinsert it when the respiratory distress subsides. 4. Pull back on the tube and wait until the respiratory distress subsides.

Pull back on the tube and wait until the respiratory distress subsides. Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus.

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

Reflecting a cultural value Rationale: Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1. Increase fluid intake. 2. Resume full activity level. 3. Stay in a cool environment when possible. 4. Monitor voiding for adequacy of urine output.

Resume full activity level. Rationale: Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the health care provider's prescriptions and anticipates that which client position will be prescribed? 1. Sims' 2. Prone 3. Supine 4. Semi Fowler's

Semi Fowler's Rationale: The client who undergoes rhinoplasty experiences swelling in the affected area. To reduce swelling, the client would be placed in the semi Fowler's position. The Sims' position, which is side-lying, would not decrease swelling. The prone and supine positions would not decrease swelling because the client would be lying flat.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? 1. Band-Aid 2. Alcohol swab 3. Povidone-iodine swab 4. Sterile 2 × 2 gauze

Sterile 2 × 2 gauze

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? 1. Stop the irrigation temporarily. 2. Increase the height of the irrigation. 3. Notify the health care provider (HCP). 4. Medicate for pain and resume the irrigation.

Stop the irrigation temporarily. If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The HCP does not need to be notified. Medicating the client for pain is not the appropriate action in this situation.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic

Taking an oral temperature for a client with a cough and nasal congestion Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution should the nurse use for the irrigation? 1. Tap water 2. Sterile water 3. Sterile distilled water 4. Sterile lactated Ringer's

Tap water

The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observation made by the instructor indicates the need for further teaching? 1. The student puts on the right glove and then the left glove. 2. The student dons the sterile gloves without washing the hands. 3. The student uses the inner wrapper of the gloves as a sterile field. 4. The student touches a glove on the overbed table, removes both gloves, and dons another sterile pair.

The student dons the sterile gloves without washing the hands. Rationale: Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. The order of placing gloves on is up to the user, as long as sterile technique is not broken. The inside wrapper provides an excellent area for use because it is sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a new package of gloves must be obtained and used.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens, and gloves only for the bath

Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.