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The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter dressing every 72 hours.
- B. Flush the catheter with heparin solution daily.
- C. Ensure the catheter is clamped when not in use.
- D. Maintain sterile technique when handling the catheter.
Correct Answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.
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A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: The correct answer is D, Speech-language pathologist. Speech-language pathologists specialize in assessing and treating dysphagia, which is a common issue following a cerebrovascular accident. They are trained to evaluate swallowing function and provide appropriate interventions to help clients improve their ability to swallow safely. Choice A, Social worker, is incorrect as their role does not typically involve addressing dysphagia specifically. Choice B, Certified nursing assistant, is not the appropriate professional to address dysphagia concerns as they do not have the training or scope of practice for this specialized area. Choice C, Occupational therapist, focuses more on activities of daily living and functional abilities rather than the specialized treatment of dysphagia.
A healthcare provider is preparing to perform mouth care for an unresponsive client. Which of the following actions should the healthcare provider plan to take?
- A. Raise the level of the bed
- B. Administer mouth care with the client in a supine position
- C. Use a tongue depressor to open the mouth
- D. Place the client in a prone position
Correct Answer: A
Rationale: Raising the bed level is the correct action to facilitate easier access for mouth care in an unresponsive client. This position enhances the safety and comfort of both the client and the healthcare provider. Administering mouth care with the client in a supine position (lying flat on their back) can increase the risk of aspiration. Using a tongue depressor to open the mouth is not recommended as it can cause discomfort and potential injury. Placing the client in a prone position (lying face down) is contraindicated for mouth care and can compromise the client's airway.
What are the correct steps used for abdominal assessment?
- A. Inspection, auscultation, percussion, palpation
- B. Palpation, inspection, auscultation, percussion
- C. Percussion, palpation, inspection, auscultation
- D. Auscultation, palpation, percussion, inspection
Correct Answer: A
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.
A client asks about the purpose of advance directives. Which of the following statements should the nurse make?
- A. They allow the court to overrule an adult client's refusal of medical treatment.
- B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
- C. They permit a client to withhold medical information from health care personnel.
- D. They allow health care personnel in the emergency department to stabilize a client's condition.
Correct Answer: B
Rationale: The correct answer is B. Advance directives specify the type of medical treatment a client wishes to receive or avoid in the event of a serious illness. Choice A is incorrect because advance directives do not allow the court to overrule a client's refusal of medical treatment; they empower the client to make their own healthcare decisions. Choice C is incorrect because advance directives do not permit a client to withhold medical information; they provide guidance on the client's treatment preferences. Choice D is incorrect because advance directives do not specifically address the actions of health care personnel in the emergency department; they focus on the client's treatment preferences in general.
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
- A. Notify the nursing manager.
- B. Document the client's condition and communication with the surgeon.
- C. Administer additional fluids as per standard procedure.
- D. Call the surgeon back immediately to ensure timely intervention.
Correct Answer: B
Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.