A nurse is caring for a client who has a peritoneal catheter that requires a dressing change.
Identify the sequence of actions the nurse should take.

Apply precut gauze pads to the site.

Create a sterile field.

Mask self and the client.

Cleanse the site with povidone-iodine.

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice E rationale

Removing the old dressing is the first step in a dressing change procedure. It must be done to visualize the site and assess for signs of infection or other complications. Proper removal also prevents contamination of the new dressing materials and allows for thorough cleansing of the area before a new dressing is applied, which is a critical step in maintaining aseptic technique.

Choice C rationale

Masking is a crucial step in maintaining a sterile field and preventing cross-contamination. Donning a mask protects the client from respiratory microorganisms of the nurse and protects the nurse from potential splashes or aerosolized particles from the client's catheter site. This step is performed after removing the old dressing but before creating the sterile field to minimize contamination risk.

Choice B rationale

Creating a sterile field is an essential step in preventing microbial contamination of the catheter site. A sterile field provides a clean, controlled environment for sterile supplies and equipment. The nurse must establish this field after donning a mask and before touching any sterile items to ensure that the materials used for the dressing change remain free of pathogens.

Choice D rationale

Cleansing the site with an antiseptic solution like povidone-iodine is a critical step to reduce the bacterial load and prevent infection. This action is performed after the sterile field is established but before applying the new dressing. The antiseptic solution disrupts microbial cell membranes and inactivates enzymes, thus reducing the risk of a catheter-associated bloodstream infection.

Choice A rationale

Applying precut gauze pads is the final step in the sequence. These pads provide a protective barrier over the cleansed site, absorb any drainage, and prevent environmental microorganisms from entering the site. This action is taken after the site has been thoroughly cleaned and dried, ensuring that the new dressing remains sterile and effective. *.

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Correct Answer is B

Explanation

Choice A rationale

Tomato soup is highly acidic due to its tomato base, which can relax the lower esophageal sphincter (LES) and increase stomach acid production. This can lead to the reflux of gastric contents into the esophagus, exacerbating the symptoms of GERD. The client should avoid highly acidic foods to manage their condition effectively.

Choice B rationale

White fish is a lean protein that is generally low in fat. High-fat foods can delay stomach emptying and decrease the pressure of the lower esophageal sphincter, increasing the risk of acid reflux. Lean proteins like white fish are less likely to trigger symptoms and are therefore a suitable dietary choice for a client with GERD.

Choice C rationale

Hot cocoa contains both caffeine and fat, which are known to exacerbate GERD symptoms. Caffeine can relax the lower esophageal sphincter, allowing stomach acid to reflux. Additionally, the fat content can delay gastric emptying, increasing pressure on the LES and worsening acid reflux symptoms.

Choice D rationale

Decaffeinated coffee can still trigger GERD symptoms. Coffee, even without caffeine, is acidic and can stimulate the production of stomach acid. The oils and compounds in coffee can also relax the lower esophageal sphincter, increasing the likelihood of acid reflux and causing irritation to the esophageal lining.

A. Veracity. B. Beneficence. C. Autonomy. D. Fidelity.

Correct Answer is A

Explanation

Choice A rationale

Veracity is the ethical principle of telling the truth and being honest with clients. By informing the client about the potential side effect of lightheadedness while also clarifying that the procedure should not affect their memory, the nurse is providing accurate and complete information. This honesty allows the client to make an informed decision and builds trust in the therapeutic relationship. The nurse is being truthful about the known risks and benefits of the treatment.

Choice B rationale

Beneficence is the ethical principle of doing good and acting in the best interest of the client. While the nurse's actions are ultimately intended to be beneficial, the specific act of providing truthful information is a demonstration of veracity. Beneficence would involve ensuring the treatment is appropriate and safe for the client, whereas veracity is the specific communication of the truth about that treatment's effects.

Choice C rationale

Autonomy is the ethical principle that respects a client's right to self-determination and to make their own decisions. While providing truthful information supports the client's ability to exercise their autonomy, the act of giving the information itself is an example of veracity. The nurse is upholding the client's autonomy by being truthful, but the action of being truthful is the core principle demonstrated.

Choice D rationale

Fidelity is the ethical principle of keeping promises and being loyal to the client. This involves maintaining professional commitments and a trusting relationship. While providing accurate information contributes to a trusting relationship, it is a direct fulfillment of the duty of veracity. Fidelity is more about honoring commitments and promises, which is a broader concept than simply telling the truth about a procedure's effects. *.

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A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take.

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A nurse is caring for a client who has a peritoneal catheter that requires a dressing change.
Identify the sequence of actions the nurse should take.