Nokea
A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?
- A. Thread the IV catheter so that the hub rests at the insertion site
- B. Shave excess hair from around the insertion site
- C. Cleanse the site with hydrogen peroxide before IV catheter insertion
- D. Palpate the site carefully just before inserting the IV catheter
Correct Answer: A
Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.
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A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
- A. Discard the first voiding.
- B. Keep the urine in a single container on ice.
- C. Include the last voiding in the collection.
- D. Instruct the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Correct Answer: A
Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.
A client who had a stroke requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Speech-language pathologist.
- D. Physical therapist.
Correct Answer: B
Rationale: The correct answer is B, Occupational therapist. An occupational therapist specializes in assisting clients with daily living activities, making them crucial for a stroke patient requiring help with morning activities of daily living (ADLs). While a registered dietitian (A) may provide nutritional guidance, a speech-language pathologist (C) focuses on communication and swallowing disorders, and a physical therapist (D) primarily deals with mobility and physical rehabilitation. However, none of these professionals directly address the specific needs related to ADLs following a stroke as effectively as an occupational therapist.
A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?
- A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
- B. A nurse asks a nurse from another unit to assist with her documentation.
- C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
- D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.
Correct Answer: B
Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.
While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?
- A. Ask the student, 'What did you forget to do?'
- B. Stop and explain why aspiration is needed.
- C. Quietly state, 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.
A client with limited mobility in his lower extremities is being cared for by a nurse. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position
- B. Increase the client's intake of carbohydrates
- C. Massage the reddened areas with unscented lotion
- D. Have the client use a trapeze bar when changing positions
Correct Answer: D
Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.