the nurse is teaching a client about the use of the syringes and needles for home administration of medications which action by the client indicates a
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

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

Correct answer: D

Rationale: Washing hands before handling needles and syringes is a crucial aspect of standard precautions to prevent infections. This practice helps reduce the risk of transferring microorganisms from the hands to the syringes and needles, thus promoting safety during medication administration.

2. When culturing a wound, the nurse should obtain the sample from which part of the wound?

Correct answer: C

Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.

3. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

4. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

5. The nurse is completing a client's preoperative routine and finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

Correct answer: C

Rationale: The nurse should inform the surgeon immediately that the operative permit is not signed and that the client has questions about the surgery. It is crucial for the surgeon to be aware of the situation so they can address the client's concerns, explain the procedure, and obtain the necessary signed permit before proceeding with the surgery. This ensures informed consent and compliance with preoperative protocols.

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