Nokea
A healthcare professional is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the healthcare professional implement to prevent infection?
- A. Thread the catheter up to the hub
- B. Use a sterile technique throughout the procedure
- C. Clean the insertion site with alcohol only
- D. Use gloves but not a mask during the procedure
Correct Answer: B
Rationale: Using a sterile technique throughout the procedure is essential to prevent infection when inserting an IV catheter. This includes maintaining aseptic conditions, using sterile equipment, and following proper hand hygiene practices. Choice A is incorrect because threading the catheter up to the hub does not specifically address infection prevention. Choice C is incorrect as cleaning the insertion site with alcohol only may not provide adequate disinfection, as it is essential to use an antiseptic solution to reduce microbial load. Choice D is incorrect as wearing gloves alone is not sufficient protection against infection; a mask should also be worn to prevent the spread of microorganisms through respiratory secretions.
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The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?
- A. Monitor the client's respiratory rate
- B. Check the client's urine output
- C. Administer the potassium chloride as a rapid IV push
- D. Dilute the potassium chloride in an appropriate IV solution
Correct Answer: D
Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.
The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct Answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.
A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Remove sutures using sterile technique.
- C. Inspect the wound for signs of infection.
- D. Document the removal of sutures.
Correct Answer: B
Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.
A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?
- A. INR of 1.5
- B. Platelet count of 200,000/mm³
- C. Hemoglobin of 12 g/dL
- D. aPTT of 70 seconds
Correct Answer: A
Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.
Which assessment data reflects the need for nurses to include the problem, "Risk for falls," in a client's plan of care?
- A. Recent serum hemoglobin level of 16 g/dL
- B. Opioid analgesic received one hour ago
- C. Stooped posture with an unsteady gait
- D. Expressed feelings of depression
Correct Answer: B
Rationale: The correct answer is B. The recent administration of opioid analgesics increases the risk for falls due to potential side effects such as sedation and dizziness. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk for falls. Choice C, stooped posture with an unsteady gait, may indicate an existing risk but does not directly reflect the need to include 'Risk for falls' in the care plan. Choice D, expressed feelings of depression, is important to address but is not directly associated with the risk for falls.