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.
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. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A tympanogram is a diagnostic test that measures the movement of the eardrum in response to changes in air pressure in the ear canal. It is used to assess the function of the middle ear and is not a part of the Weber's test. The Weber's test is a gross screening tool for hearing acuity that uses a vibrating tuning fork to compare bone conduction in both ears, not to evaluate middle ear function.
Choice B rationale
The Weber's test is a simple screening tool to detect unilateral hearing loss. The nurse places a vibrating tuning fork on the midline of the child's head, such as the forehead or the top of the head. The sound is transmitted through the skull bones to the inner ears. The child is asked where the sound is heard best—in the left ear, right ear, or equally in both. This assesses bone conduction.
Choice C rationale
The Weber's test evaluates whether the sound is heard equally in both ears or lateralizes to one ear, indicating a potential conductive or sensorineural hearing loss. It does not measure the duration of sound perception. Measuring the amount of time a client can hear the sound after the tuning fork is placed on the mastoid bone is part of the Rinne test, a different component of hearing assessment, which compares bone and air conduction.
Choice D rationale
Holding a vibrating tuning fork 1 to 2 cm from the ear canal is a procedure used for the Rinne test, not the Weber's test. The Rinne test compares air conduction to bone conduction. The vibrating tuning fork is placed first on the mastoid bone (bone conduction) and then near the ear canal (air conduction). This is used to distinguish between conductive and sensorineural hearing loss. *.
Correct Answer is C
Explanation
Choice A rationale
Ketonuria, the presence of ketones in the urine, is typically associated with hyperglycemia and diabetic ketoacidosis. When glucose levels are high and cells can't use it for energy, the body starts breaking down fats, producing ketones as a byproduct. A blood glucose reading of 64 mg/dL is low and indicates hypoglycemia, not hyperglycemia.
Choice B rationale
Warm skin is a sign of vasodilation, often associated with a fever or an inflammatory response. In the context of hypoglycemia, the sympathetic nervous system is activated, leading to vasoconstriction, which would typically cause the skin to feel cool and clammy, not warm.
Choice C rationale
Nervousness is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases counterregulatory hormones like epinephrine and norepinephrine from the adrenal glands. This sympathetic nervous system activation causes symptoms such as nervousness, anxiety, palpitations, and tremors as the body attempts to raise blood sugar.
Choice D rationale
Tachypnea, or rapid breathing, is a clinical finding associated with metabolic acidosis, such as diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the high acid load by increasing the respiratory rate to blow off carbon dioxide. It is not a typical symptom of hypoglycemia, which is indicated by a reading of 64 mg/dL. .
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