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A practical nurse is preparing to enter a client's room. What is the first
action the nurse should perform to prevent the spread of infection?
Answer: Perform hand hygiene.
Rationale: Hand hygiene is the single most effective intervention for
preventing healthcare-associated infections. The nurse should cleanse
hands with soap and water or an alcohol-based hand rub before and
after every client contact, before performing aseptic procedures, after
exposure to body fluids, and after touching the client's environment.
A nurse is preparing to identify a client before administering
medication. Which identifiers should be used?
Answer: Use two approved client identifiers, such as the client's full
name and date of birth or medical record number.
,Rationale: Using two identifiers reduces the risk of administering
medications or treatments to the wrong client. Room numbers should
never be used as identifiers because clients may change rooms during
hospitalization.
A client is at high risk for falls. What is the priority nursing intervention?
Answer: Implement fall precautions immediately.
Rationale: Fall prevention includes placing the bed in the lowest
position, ensuring the call light is within reach, providing non-skid
footwear, keeping frequently used items nearby, and educating the
client to request assistance before ambulating.
What is the nurse's priority action after discovering an unresponsive
client?
Answer: Assess responsiveness, activate the emergency response
system, and assess breathing and pulse.
Rationale: The nurse follows Basic Life Support (BLS) guidelines by first
assessing responsiveness, calling for help, checking breathing and pulse
simultaneously, and initiating CPR if indicated.
, A client refuses a prescribed medication. What should the nurse do
first?
Answer: Determine the client's reason for refusing the medication.
Rationale: Clients have the legal right to refuse treatment. The nurse
should assess the reason, provide education if appropriate, notify the
provider when necessary, and document the refusal and interventions.
Which assessment finding should the nurse report immediately?
Answer: A sudden oxygen saturation of 84%.
Rationale: An oxygen saturation of 84% indicates significant hypoxemia
requiring immediate intervention to prevent respiratory compromise
and tissue hypoxia.
Before performing a sterile dressing change, what is the most
important nursing action?
Answer: Verify the provider's prescription and gather sterile supplies.