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A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.
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A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares, face, and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the correct action because excessive oxygen flow can lead to oxygen toxicity and respiratory depression in patients. Nasal cannulas are commonly used for oxygen therapy and a flow rate of more than 6 L/min can cause discomfort and dryness of the nasal passages. It is important to adhere to evidence-based practice guidelines to ensure patient safety and well-being.
Choice A is incorrect because aligning the flow rate with the top of the ball inside the flow meter is not a reliable method for regulating oxygen flow. Choice C is incorrect as the reservoir bag of a partial rebreathing mask should remain inflated to ensure an adequate oxygen supply. Choice D is incorrect as petroleum jelly should not be used in oxygen therapy due to the risk of flammability.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine.
- B. How to secure the tracheostomy tube with ties at the back of the neck.
- C. How to change the nondisposable tracheostomy tube daily.
- D. How to change the tracheostomy dressing using clean technique.
Correct Answer: D
Rationale: The correct answer is D: How to change the tracheostomy dressing using clean technique. This is important to prevent infection and promote healing. First, wash hands thoroughly to maintain cleanliness. Second, gather necessary supplies such as clean gloves, sterile gauze, and saline solution. Third, remove the old dressing carefully and inspect the stoma for any signs of infection or irritation. Fourth, clean around the stoma with saline solution and gently pat dry. Finally, apply a new, sterile dressing using clean technique to maintain a clean and dry environment. Choice A is incorrect because operating a suction machine is typically done by healthcare professionals. Choice B is incorrect as securing the tracheostomy tube is usually done by healthcare providers to ensure proper placement. Choice C is incorrect as changing the tracheostomy tube daily is not a standard practice unless specifically indicated by a healthcare provider.
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Herbal remedies
- D. Acupuncture
Correct Answer: A
Rationale: The correct answer is A: Biofeedback. Biofeedback involves monitoring and controlling bodily functions to reduce pain and stress. In the case of herpes zoster, the skin lesions can be very sensitive, making it uncomfortable for the client to participate in biofeedback sessions. Additionally, the focus required for biofeedback may be challenging for someone experiencing pain from herpes zoster.
B: Aloe is a natural remedy that can be used topically to soothe skin irritations, including herpes zoster lesions. However, it may not provide adequate pain control.
C: Herbal remedies can be used to help manage pain in herpes zoster, such as capsaicin cream. While some herbal remedies may interact with medications, there is no general contraindication for their use in herpes zoster.
D: Acupuncture is a complementary therapy that involves inserting thin needles into specific points on the body to alleviate pain. It can be effective for pain relief in herpes zoster and is not contraindicated
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr.
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rail.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to ensure the safety and well-being of the client in restraints. Documenting the client's condition frequently allows for timely identification of any signs of distress, discomfort, or complications related to the use of restraints. This practice helps in monitoring the client's physical and psychological status, enabling prompt intervention if necessary.
Removing the client's restraint every 4 hours (choice A) is incorrect as it may compromise the client's safety and increase the risk of injury or harm. Requesting a PRN restraint prescription for aggressive clients (choice C) is inappropriate as restraints should only be used as a last resort and not for convenience. Attaching the restraint to the bed's side rail (choice D) is unsafe and restricts the client's movement unnecessarily.