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 A
Explanation
Choice A rationale
The first step in inserting an indwelling urinary catheter, after gathering supplies and preparing the client, is to lubricate the tip. The application of a generous amount of water-soluble gel to the catheter tip reduces friction as it passes through the urethra. This is crucial for minimizing trauma to the urethral mucosa and decreasing client discomfort during insertion.
Choice B rationale
Positioning the sterile drape is a later step in the procedure, after the catheter has been prepared for insertion. The drape is used to create a sterile field and isolate the perineum. This helps prevent contamination of the sterile catheter and gloves from surrounding non-sterile areas, which is essential for maintaining sterility and preventing infection.
Choice C rationale
Cleansing the meatus with an antiseptic solution is a critical step, but it is performed after the catheter is lubricated and the sterile field is established. This action mechanically and chemically removes microorganisms from the perineal area, reducing the risk of introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Attaching a prefilled syringe to the inflation hub is done after the catheter is fully inserted into the bladder and urine flow is established. This step is necessary to inflate the balloon, which secures the catheter in place and prevents it from being expelled. Doing this prematurely could cause urethral damage. *.
Correct Answer is D
Explanation
Choice A rationale
Postterm pregnancy, defined as a gestation extending beyond 42 weeks, is not a contraindication for misoprostol. In fact, it is a common indication for labor induction, as the placenta may begin to deteriorate, increasing the risk of fetal distress and meconium aspiration. Misoprostol, a prostaglandin E1 analog, helps ripen the cervix and stimulate uterine contractions. This pharmacologic action is beneficial in initiating labor in postterm pregnancies.
Choice B rationale
Transverse fetal lie is an obstetrical position where the fetus is lying sideways across the uterus. This position poses a significant risk of complications during vaginal birth, including uterine rupture and umbilical cord prolapse. Therefore, any attempt to induce labor with a medication like misoprostol is contraindicated. Cesarean delivery is typically the preferred method of delivery in cases of persistent transverse lie to ensure a safe delivery for both mother and fetus.
Choice C rationale
Intrauterine growth restriction (IUGR) is a condition where a fetus is smaller than expected for gestational age. It is not a contraindication for misoprostol. Often, IUGR is an indication for labor induction to prevent further fetal compromise. Misoprostol is a commonly used medication for this purpose, as it helps to initiate cervical ripening and uterine contractions, which can lead to a successful vaginal delivery.
Choice D rationale
A history of a cesarean section is a significant contraindication for misoprostol because it substantially increases the risk of uterine rupture. Misoprostol causes potent uterine contractions that can place undue stress on the uterine scar from the previous surgery. The risk of rupture is a life-threatening complication for both the mother and the fetus. Therefore, other methods of labor induction or a planned repeat cesarean section are often considered. *.
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