A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Choice A rationale:

"You will need to sign a consent form before we begin the procedure." Rationale: While obtaining consent is an essential part of many medical procedures, including a bladder scan, it is not specific to the teaching related to the procedure itself. It addresses the legal and ethical aspect of the procedure but doesn't instruct the client on what to expect during the procedure.

Choice B rationale:

"I will place a gel pad directly above your pubic area before I place the probe." Rationale: This is the correct choice. Placing a gel pad above the pubic area before using the probe is an important step in ensuring proper ultrasound transmission and obtaining accurate results during a bladder scan. The gel pad helps to eliminate air gaps that could interfere with the quality of the scan.

Choice C rationale:

"You will need to hold your urine for 1 hour prior to the procedure." Rationale: Holding urine for an hour before a bladder scan might be required to ensure that the bladder is adequately filled for the scan, but it doesn't address the specific preparation related to the ultrasound procedure itself.

Choice D rationale:

"You will receive a contrast dye through an IV catheter prior to the scan." Rationale: Mentioning contrast dye and IV catheter is not relevant to a bladder scan. Contrast dye is often used in imaging studies like CT scans or angiograms, but not for a routine bladder scan. Therefore, this instruction is unrelated to the procedure in question.

The correct answer is choice d. Actual loss.

Choice A rationale: Complicated grief refers to an intense and prolonged period of mourning that interferes with daily life. It is not typically associated with the immediate postoperative period following a mastectomy.

Choice B rationale: Maturational loss is related to the normal life transitions and developmental changes, such as children leaving home or retirement. It does not apply to the loss experienced after a mastectomy.

Choice C rationale: Disenfranchised grief occurs when a person’s grief is not socially recognized or supported, such as the loss of a pet or an ex-spouse. While the grief after a mastectomy can be profound, it is generally acknowledged and supported by healthcare providers and society.

Choice D rationale: Actual loss refers to the tangible loss of a person, object, or body part. In this case, the client is experiencing the loss of a breast, which is a significant and visible change to their body. This type of loss can deeply affect a person’s self-image and emotional well-being.