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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Remove the old dressing.

Create a sterile field.

Apply precut gauze pads to the site.

Mask self and the client.

Answer and Explanation

The Correct Answer is D,A,B,C

the correct sequence is D, A, B, C. Rationale: D (Mask self and the client): First, both the nurse and the client should wear masks to reduce the risk of infection during the procedure. A (Remove the old dressing): Next, the old dressing should be removed to expose the site. B (Create a sterile field): After removing the old dressing, a sterile field is created to maintain aseptic conditions. C (Apply precut gauze pads to the site): Finally, sterile precut gauze pads are applied to the site to protect the catheter.

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Correct Answer is D

Explanation

A. Lift the traction weights when repositioning the child in bed.

This action should not be included in the plan of care because lifting the traction weights can interfere with the traction's effectiveness and potentially cause harm or injury to the child. The weights are specifically calibrated to provide the necessary tension for the traction to stabilize the fracture site.

B. Have the child rate their level of pain every 8 hours.

While pain assessment is an essential component of nursing care, the frequency of every 8 hours may not be sufficient, especially for a child in skeletal traction. Pain management should be more frequent and individualized based on the child's needs, which may vary throughout the day.

C. Monitor the neurovascular status of the child's lower extremities every 12 hours.

Neurovascular assessment is crucial for patients in traction to detect any signs of compromised circulation or nerve function. However, every 12 hours may not be frequent enough to promptly identify changes in neurovascular status. More frequent assessments, such as every 1-2 hours initially and then gradually decreasing based on stability, are typically recommended.

D. Educate the child's guardians about pin site care prior to discharge.

This is the correct answer. Educating the child's guardians about pin site care is essential to prevent infection and other complications associated with skeletal traction. Proper care of the pin sites reduces the risk of infection, which can lead to serious complications such as osteomyelitis. Providing education prior to discharge ensures that the guardians are equipped with the necessary knowledge and skills to care for the child at home effectively.

A. Provide the client with a low-protein diet. B. Ambulate the client every 4 hr. C. Ensure that the side rails are up on the client's bed. D. Check the fetal heart rate twice daily.

Correct Answer is C

Explanation

A. Provide the client with a low-protein diet: Clients with severe preeclampsia may require dietary modifications, but a low-protein diet is not typically indicated. Instead, they may need a balanced diet with adequate protein intake to support maternal and fetal health.
B. Ambulate the client every 4 hr: Ambulation may not be suitable for a client with severe preeclampsia due to the risk of seizures and other complications associated with the condition. Bed rest or limited activity is often recommended to reduce the risk of adverse outcomes.
C. Ensure that the side rails are up on the client's bed: This action is crucial for the safety of the client with severe preeclampsia, as they are at risk of seizures, which can lead to injury from falls. Keeping the side rails up helps prevent falls and ensures the client's safety during periods of altered consciousness.
D. Check the fetal heart rate twice daily: Monitoring the fetal heart rate is essential in managing severe preeclampsia to assess fetal well-being and detect signs of fetal distress. However, the frequency of monitoring may vary depending on the severity of the condition and the healthcare provider's orders. More frequent monitoring may be necessary in some cases.

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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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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