Page 51 - Saunders Comprehensive Review For NCLEX-RN
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assessed first so that treatment can be implemented. Although the clients in options
1, 2, and 3 have needs that require assessment, their assessments can wait until the
client in the correct option is stabilized.
Safety and Infection Control
The nurse prepares to care for a client on contact precautions who has a hospital-
acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The
client has an abdominal wound that requires irrigation and has a tracheostomy
attached to a mechanical ventilator, which requires frequent suctioning. The nurse
should assemble which necessary protective items before entering the client’s room?
1. Gloves and gown
2. Gloves and face shield
3. Gloves, gown, and face shield
4. Gloves, gown, and shoe protectors
Answer: 3
This question addresses the subcategory Safety and Infection Control in the Client
Needs category Safe and Effective Care Environment. It addresses content related to
protecting oneself from contracting an infection and requires that you consider the
methods of possible transmission of infection, based on the client’s condition. Note
the data in the question. Because of the potential for splashes of infective material
occurring during the wound irrigation or suctioning of the tracheostomy, option 3 is
correct.
Health Promotion and Maintenance
The Health Promotion and Maintenance category addresses the principles related to
growth and development. According to the NCSBN, this Client Needs category also
addresses content required to assist the individual to prevent health problems; to
recognize alterations in health; and to develop health practices that promote and
support optimal wellness. See Box 1-3 for an example of a question in this Client
Needs category.
Box 1-3
Health Promotion and Maintenance
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best
choice for this age?
1. Puzzle
2. Toy soldiers
3. Large stacking blocks
4. A card game with large pictures
Answer: 3
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