when caring for a patient with latex allergy the nurse creates a latex safe environment by doing which of the following

NCLEX-RN

NCLEX RN Predictor Exam

1. When caring for a patient with latex allergy, the healthcare provider creates a latex-safe environment by doing which of the following?

A. Carefully cleaning the wall-mounted blood pressure device before using it.
B. Donning latex gloves outside the room to limit powder dispersal.
C. Using a latex-free pharmacy protocol.
D. Placing the patient in a semi-private room.

Correct answer: C

Rationale: Creating a latex-safe environment for a patient with latex allergy is crucial to prevent allergic reactions. Using a latex-free pharmacy protocol is essential as it ensures that medications and supplies provided to the patient are free of latex components. Cleaning a wall-mounted blood pressure device may not be sufficient as the device itself may contain latex parts that can trigger an allergic reaction. Donning latex gloves, even outside the room, is not recommended as powder dispersal can cause issues; only non-latex gloves should be used in a latex-safe environment. Placing the patient in a semi-private room does not directly address the need to eliminate latex exposure from medical supplies and equipment, which is better achieved through a latex-free pharmacy protocol.

2. In the Gram Stain procedure, which component acts as the mordant?

A. Crystal violet
B. Methyl alcohol
C. Iodine
D. Safranin

Correct answer: C

Rationale: In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.

3. Which statement best describes evidence-based practice?

A. Reading and analyzing research reports to determine their implementation in nursing practice
B. Collecting data to evaluate the efficiency of nursing practice in delivering quality care
C. Monitoring unit practices to ensure adherence to Joint Commission standards
D. Using the most effective, current, and applicable information to guide nursing care for the best outcomes

Correct answer: D

Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.

4. During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?

A. "Is a personal search to discover a supreme being."?
B. "Is an organized system of beliefs concerning the cause, nature, and purpose of the universe."?
C. "Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife."?
D. "Focuses on a connection with something bigger than oneself and a belief in transcendence."?

Correct answer: D

Rationale: Spirituality is a broad term that focuses on a connection with something greater than oneself and a belief in transcendence. It is a personal journey that arises from unique life experiences and the individual's quest to find purpose and meaning in life. The correct answer emphasizes the essence of spirituality, which involves seeking a connection with a higher power and believing in transcendence. Choices A, B, and C, on the other hand, define aspects of religion rather than spirituality. Choice A refers to a personal search for a supreme being, which is more aligned with religious beliefs. Choice B describes an organized system of beliefs about the universe, typically associated with religion. Choice C pertains to beliefs about existence after death, such as reincarnation or the afterlife, which are often religious concepts. Therefore, the best description of spirituality is focusing on a connection with something beyond oneself and a belief in transcendence.

5. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

A. Assist the client to lie in the semi-Fowler position
B. Apply lubricating jelly to the tip of the catheter before insertion
C. Instill a total of 30cc of fluid into the client's rectum
D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.