Nokea
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
- A. Promote client autonomy
- B. Maintain family dynamics and support
- C. Maintains privacy and confidentiality
- D. Prevent potential intimidation or coercion
- E. Minimize the risk of retaliation
Correct Answer: A,C,D,E
Rationale: Excluding family promotes autonomy, privacy, and prevents intimidation or retaliation. Maintaining family dynamics is not a priority in this context.
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The nurse is removing an indwelling urinary catheter
Item 1 of 1
Nurses Note
The removal of the client’s indwelling urinary catheter was attempted. Perineal hygiene was performed before the removal. The urine collection bag was emptied with 450 mL of clear, straw-colored urine. 2 mL of fluid was removed during the deflation of the balloon. Resistance was felt when the tubing was removed, and the client reported discomfort.
Drag words from the choices below to fill the blank in the following sentence. Prior to attempting to remove the catheter again, the nurse should--------------------------
- A. place a warm compress over the perineum
- B. cut the balloon inflation valve
- C. position the client at 45 degrees
- D. further deflate the catheter balloon
Correct Answer: D
Rationale: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter.
Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the dorsal recumbent position.
Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been entirely deflated.
The nurse is conducting a staff conference regarding standard precautions. It would be correct for the nurse to state that hand washing with soap and water is required when
- A. Hands are visibly soiled.
- B. Collecting vital signs (VS).
- C. Performing range of motion exercises.
- D. Inputting data into the electronic medical record (EMR).
Correct Answer: A
Rationale: Soap and water are required for visibly soiled hands, as alcohol-based rubs are less effective. Other activities can use hand rubs unless soiled.
The nurse is conducting an in-service for nursing students. It would be appropriate for the nurse to state which of the following procedures requires a sterile technique? Select all that apply.
- A. Changing the dressing for a central line
- B. Inserting an indwelling urinary catheter
- C. Removing a peripheral vascular access device
- D. Suctioning an endotracheal tube with in-line suction
- E. Inserting a nasogastric tube (NGT)
Correct Answer: A,B,D
Rationale: Sterile technique is required for central line dressing changes, indwelling urinary catheter insertion, and endotracheal suctioning due to the risk of introducing pathogens into sterile areas.
The nurse is discussing infection control with a group of nursing students. Which indication would be appropriate for the nurse to use an alcohol-based sanitizer? Select all that apply.
- A. Immediately before touching a client
- B. After applying sterile gloves
- C. When changing linens for a client infected with Clostridium difficile
- D. After changing a diaper for an infant infected with norovirus
- E. After collecting vital signs on a client with human immunodeficiency virus (HIV)
Correct Answer: A,E
Rationale: Alcohol-based sanitizers are effective before touching a client and after non-soiled contact like vital signs for HIV. They are ineffective for C. difficile or norovirus, and hand washing is needed after applying gloves.
The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with
- A. Heart failure receiving diuretics
- B. Bacterial meningitis receiving antibiotics
- C. Prostate cancer receiving brachytherapy
- D. Varicella prescribed antivirals
Correct Answer: A
Rationale: Hepatitis B is transmitted via blood/body fluids, so rooming with a heart failure client is safe. Meningitis, varicella, and brachytherapy require specific precautions or isolation.