A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?
Instilling an ophthalmic ointment for a client who has a corneal abrasion
Inserting an NG tube for a client who needs continuous enteral feedings
Changing a central venous catheter dressing for a client who is receiving IV therapy
Administering an IM injection to a client who has bacterial pneumonia
The Correct Answer is C
The correct answer is choice C. Changing a central venous catheter dressing for a client who is receiving IV therapy. Choice A rationale: Instilling ophthalmic ointment typically does not require sterile gloves. Clean technique is sufficient as long as proper hand hygiene is performed to prevent infection. Choice B rationale: Inserting an NG tube requires clean technique, not sterile. The procedure is performed through the nasal passage and esophagus, which are not sterile environments. Choice C rationale: Changing a central venous catheter dressing requires sterile gloves to prevent introducing infection into the bloodstream. Central lines are a direct pathway to the central circulation, making aseptic technique critical to prevent serious infections such as bloodstream infections. Choice D rationale: Administering an IM injection requires clean technique. The skin is cleaned with an antiseptic wipe before the injection, but sterile gloves are not necessary for this procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
At the hip region is incorrect because it does not specify any clinical manifestation indicative of scoliosis.
Choice B reason
Uneven shoulder and pelvic heights are the correct position. Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often causing the spine to appear as an "S" or "C" shape when viewed from the back. When performing scoliosis screenings, the school nurse should look for signs that may indicate scoliosis, such as uneven shoulder and pelvic heights.
Choice C reason:
United tinge of moben of the hips is incorrect because it does not describe a known clinical manifestation of scoliosis and appears to contain typographical errors.
Choice D reason:
Exaggerated curvature of the sacrum is incorrect because it is not a characteristic clinical manifestation of scoliosis. The curvature of the sacrum is normal and not related to scoliosis.
Correct Answer is D
Explanation
Choice A reason
Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.
Choice B reason:
Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.
Choice C reason:
Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.
Choice D reason:
When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.
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