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 D
Explanation
Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.
Correct Answer is D
Explanation
The correct answer is D. Heart rhythm. Hypothermia can cause cardiac dysrhythmias such as bradycardia, atrial fibrillation, and ventricular fibrillation, which can lead to cardiac arrest.
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