Question

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?

Answer 1

Correct Answers:

Gloves

Rationale :

🧤 Gloves are the most contaminated piece of PPE after a procedure.

🧤 Removing gloves first reduces risk of contaminating other PPE or surfaces.

🧤 Gown, mask, and face shield are removed after gloves to maintain protection.

🧤 Proper PPE removal follows CDC sequence to prevent pathogen transmission.

🧤 Supports infection control and safe donning/doffing practices.

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Answer 2

Correct Answers:

"This service assists with making me comfortable during my illness."

Rationale :

💖 Palliative care focuses on comfort, symptom management, and quality of life.

💖 Can include support for caregivers and daily activities, but primary goal is comfort.

💖 Understanding ensures the client recognizes the goal is not curative treatment.

💖 Services are flexible and patient-centered.

💖 Promotes informed decision-making about end-of-life care.

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Answer 3

Correct Answers:

Infiltration

Rationale :

💧 Cool, taut skin at the IV site indicates fluid leaking into surrounding tissue.

💧 IV fluid leaking confirms non-vesicant solution is entering subcutaneous tissue.

💧 Infection would typically show redness, warmth, and purulent drainage.

💧 Circulatory overload presents with bounding pulses, edema, and crackles, not local IV changes.

💧 Phlebitis shows red streaks, tenderness, and warmth, distinct from infiltration.

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Answer 4

Correct Answers:

Purplish-colored stoma

Rationale :

🩹 Purplish color indicates ischemia or compromised blood flow.

🩹 Shiny, moist stoma is normal and healthy.

🩹 Rosebud-like stoma or oozing red drainage can be expected post-op.

🩹 Early identification prevents tissue necrosis and serious complications.

🩹 Immediate reporting supports timely intervention.

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Answer 5

Correct Answers:

Draw the Regular insulin first, then the NPH insulin.

Rationale :

💉 Clear (Regular) insulin is drawn first to avoid contaminating it with cloudy NPH insulin.

💉 Cloudy (NPH) insulin is drawn after the Regular insulin in the same syringe.

💉 Mixing insulins in separate syringes is possible but less efficient for one injection.

💉 Proper mixing ensures accurate dosing and maintains insulin efficacy.

💉 Avoid inverting or shaking insulin to prevent air bubbles and denaturation.

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Answer 6

Correct Answers:

A nurse fulfills a promise to a client that they will return with their pain medication.

Rationale :

🤝 Fidelity involves keeping promises and commitments to patients.

🤝 Builds trust and therapeutic nurse-patient relationships.

🤝 Administering scheduled medication reflects responsibility, not necessarily fidelity.

🤝 Allowing refusal demonstrates autonomy.

🤝 Providing nonpharmacological interventions equally reflects justice/equity, not fidelity.

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Answer 7

Correct Answers:

Preparing a Meal

Rationale :

🍽️ Instrumental activities of daily living (IADLs) are complex daily tasks required for independent living.

🍽️ Examples include meal preparation, managing finances, shopping, and using transportation.

🍽️ Basic activities like bathing, dressing, and feeding are ADLs (Activities of Daily Living).

🍽️ Assisting with IADLs promotes independence and functional status.

🍽️ Helps assess patient needs for home or assisted care planning.

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Answer 8

Correct Answers:

Discard the first voiding.

Rationale :

🧪 24-hour urine collection begins after the first voiding is discarded.

🧪 All subsequent urine is collected in a single container for 24 hours.

🧪 First voiding contains residual substances that could skew results.

🧪 Urine should be refrigerated or kept on ice, not at room temperature.

🧪 Proper technique ensures accurate lab results and patient education.

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Answer 9

Correct Answers:

The patient will walk 50 feet using a walker by 9/15/2025.

Rationale :

🎯 SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound.

🎯 “Walk 50 feet” is specific and measurable.

🎯 Includes target date for achievement.

🎯 Provides clear criteria for evaluating progress.

🎯 Other options are vague and non-measurable.

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Answer 10

Correct Answers:

Ask the client to demonstrate walking with the cane.

Rationale :

👀 Evaluation step assesses whether learning objectives were achieved.

👀 Demonstration shows client’s ability to perform the skill independently.

👀 Determining readiness occurs in assessment.

👀 Identifying short-term goals occurs in planning.

👀 Showing a video occurs in implementation/teaching.

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QLexNursing

1 :
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?

2 :
A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications?

4 :
A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

5 :
Mr. Brown, a 50-year-old patient with Type 1 Diabetes, is prescribed 10 units of Regular insulin (clear) and 20 units of NPH insulin (cloudy) to be administered subcutaneously before breakfast. Describe the correct procedure for mixing these insulins

6 :
A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of fidelity?

7 :
A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will most likely be assisting the patient with which activity?

8 :
A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take?

9 :
The nurse is writing an expected outcome for a patient with impaired mobility. Which statement best reflects the SMART model for goal setting?

10 :
A nurse is preparing a teaching plan for a client who is learning to walk with a cane. The nurse should identify that which of the following actions is part of the evaluation step of the teaching plan?

QLexNursing

1 : A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?

2 : A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications?

4 : A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

5 : Mr. Brown, a 50-year-old patient with Type 1 Diabetes, is prescribed 10 units of Regular insulin (clear) and 20 units of NPH insulin (cloudy) to be administered subcutaneously before breakfast. Describe the correct procedure for mixing these insulins

6 : A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of fidelity?

7 : A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will most likely be assisting the patient with which activity?

8 : A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take?

9 : The nurse is writing an expected outcome for a patient with impaired mobility. Which statement best reflects the SMART model for goal setting?

10 : A nurse is preparing a teaching plan for a client who is learning to walk with a cane. The nurse should identify that which of the following actions is part of the evaluation step of the teaching plan?

1 :
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?

2 :
A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications?

4 :
A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

5 :
Mr. Brown, a 50-year-old patient with Type 1 Diabetes, is prescribed 10 units of Regular insulin (clear) and 20 units of NPH insulin (cloudy) to be administered subcutaneously before breakfast. Describe the correct procedure for mixing these insulins

6 :
A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of fidelity?

7 :
A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will most likely be assisting the patient with which activity?

8 :
A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take?

9 :
The nurse is writing an expected outcome for a patient with impaired mobility. Which statement best reflects the SMART model for goal setting?

10 :
A nurse is preparing a teaching plan for a client who is learning to walk with a cane. The nurse should identify that which of the following actions is part of the evaluation step of the teaching plan?