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What action should be taken to maintain the patency of a peripherally inserted central catheter (PICC)?
- A. Flush the catheter with heparin solution daily.
- B. Change the dressing at the insertion site daily.
- C. Use sterile technique when changing the dressing.
- D. Keep the insertion site dry at all times.
Correct Answer: C
Rationale: The correct answer is to use sterile technique when changing the dressing. This practice is essential for preventing infections that can compromise the patency of the PICC line. While flushing the catheter with heparin solution helps prevent clot formation, it does not directly maintain patency. Changing the dressing daily is important for hygiene but does not have a direct impact on catheter patency. Keeping the insertion site dry is crucial to prevent infections but does not specifically address patency maintenance.
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The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?
- A. I will reduce my salt intake.
- B. I will exercise for 30 minutes most days of the week.
- C. I will drink alcohol only on the weekends.
- D. I will monitor my blood pressure regularly.
Correct Answer: C
Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.
A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
- A. Wear gloves when changing the client's gown.
- B. Use hand sanitizer after contact with the client.
- C. Wear a mask when entering the client's room.
- D. Clean the room with a disinfectant spray.
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.
A client is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
- A. Ensure two fingers can fit under the sleeves.
- B. Ensure the device is not too tight to impede circulation.
- C. Position the client comfortably before applying the device.
- D. Use the device continuously to prevent blood clots.
Correct Answer: A
Rationale: The correct action for the nurse to take when applying a thigh-length sequential compression device to a postoperative client is to ensure that two fingers can fit under the sleeves. This action helps prevent the device from being too tight, which could impede circulation. Choice B is incorrect because the device should not be too tight, as it could lead to circulation issues. Choice C is incorrect as the client should be in a comfortable position, not necessarily supine. Choice D is incorrect as sequential compression devices are typically used continuously to prevent blood clots.
The nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?
- A. Use the complete name of the medication magnesium sulfate.
- B. Avoid abbreviating medication names to prevent errors.
- C. Use generic names only for medications.
- D. Document the dosage, route of administration, and complete medication name.
Correct Answer: A
Rationale: The correct answer is A: 'Use the complete name of the medication magnesium sulfate.' When documenting medications, it is crucial to use the complete name to avoid confusion and errors. Abbreviating medication names (choice B) can lead to misinterpretation and errors in medication administration. Using generic names only for medications (choice C) may not provide enough specificity, leading to potential medication errors. While documenting the dosage and route of administration is important, it is also vital to include the complete medication name (choice D) for accurate record-keeping and to ensure clarity in medication administration.
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?
- A. Remove the needle after discarding used syringes
- B. Wear gloves while disposing of the needle and syringe
- C. Wear a face mask during medication administration
- D. Wash hands before handling the needle and syringe
Correct Answer: D
Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.