Nokea
A nurse is preparing to assist with a peripherally inserted central catheter (PICC) insertion for a patient. What action should the nurse prioritize to maintain procedural asepsis?
- A. Wearing sterile gloves and a surgical mask during the procedure
- B. Cleansing the insertion site with alcohol-based antiseptic solution
- C. Using a sterile drape to cover the patient during the procedure
- D. Avoiding unnecessary movement or talking during the procedure
Correct Answer: B
Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.
You may also like to solve these questions
A patient is complaining of urinary pain after being diagnosed with a urinary tract infection the previous day. What is the nurse's best action?
- A. Administer ordered phenazopyridine hydrochloride (Pyridium).
- B. Administer ordered trimethoprim (Trimpex).
- C. Administer ordered bethanechol (Urecholine).
- D. Administer ordered acetaminophen (Tylenol) and a warm bath.
Correct Answer: B
Rationale: The nurse's best action in this situation would be to administer the ordered antibiotic trimethoprim (Trimpex). A urinary tract infection (UTI) requires antibiotic treatment to eliminate the bacterial infection causing the symptoms. Phenazopyridine hydrochloride is a urinary tract analgesic that can help relieve urinary pain but does not treat the infection itself. Bethanechol is a cholinergic medication used to treat urinary retention, not a UTI. Acetaminophen and a warm bath may help with some discomfort but do not address the underlying infection causing the urinary pain. Therefore, administering the prescribed antibiotic would be the most appropriate action to target the source of the patient's symptoms.
Evelyn was given iron as supplemental vitamin to prevent maternal anemia. She asks if
- A. Which of the following would be the best response of the nurse?
- B. "Take two other vitamins separately."
- C. Absorption of iron is enhanced with Vit C.
- D. "Drink milk when taking the iron supplement."
Correct Answer: C
Rationale: The correct response would be "Absorption of iron is enhanced with Vitamin C." Iron absorption is increased in the presence of Vitamin C. Therefore, recommending Evelyn to take her iron supplement with a source of Vitamin C such as orange juice or a Vitamin C tablet would optimize the absorption of iron in her body and help prevent maternal anemia more effectively. Taking iron with other vitamins separately, after a full meal, or with milk would not have the same beneficial effect on iron absorption as combining it with Vitamin C.
A postpartum client who delivered twins expresses concerns about breastfeeding both infants simultaneously. What nursing intervention should be prioritized to address the client's concerns?
- A. Demonstrating tandem breastfeeding positions and techniques
- B. Recommending the use of nipple shields to facilitate latch for both infants
- C. Encouraging the client to alternate breastfeeding sessions between the infants
- D. Referring the client to a lactation consultant for assistance
Correct Answer: A
Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.
She was asked by the nurse supervisor about her concern and what are the considered ideal fetal positions for a healthy delivery?
- A. Right occipitoposterior with no flexion
- B. Right occipitoposterior with full flexion
- C. Left transverse anterior in moderate flexion
- D. Left Sacroanterior with full flexion
Correct Answer: C
Rationale: The considered ideal fetal position for a healthy delivery is left transverse anterior with moderate flexion. This position allows for an easier descent through the birth canal and reduces the chances of complications during delivery. This position is optimal for a smoother and safer delivery process for both the mother and the baby.
The immunity conferred by tetanus toxoid is best described as:
- A. Lifelong passive
- B. Temporary passive
- C. Long-lasting active
- D. Lifelong active
Correct Answer: C
Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.