In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

Leave the saline lock in place and notify the charge nurse.

Plan to apply pressure over the site for several minutes.

Encourage the client to drink additional oral fluids.

Prepare a warm pack to apply after removing the lock

Answer and Explanation

The Correct Answer is B

Antiplatelet medications, such as aspirin or clopidogrel, are prescribed to prevent the formation of blood clots by inhibiting platelet aggregation. These medications can increase the risk of bleeding or prolonged bleeding time. Therefore, when removing the saline lock, applying pressure over the site for several minutes helps to minimize the risk of bleeding and promote hemostasis.
A. Leaving the saline lock in place and notifying the charge nurse may not be necessary unless there are specific concerns or complications related to the client's condition.
C. Encouraging the client to drink additional oral fluids is not directly related to the discontinuation of the saline lock and the potential risk of bleeding associated with antiplatelet medication.
D. Preparing a warm pack to apply after removing the lock is not necessary for this situation. Warm packs are typically used for comfort or to promote circulation, but they are not directly related to the risk of bleeding associated with antiplatelet medication.

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Correct Answer is D

Explanation

Choice A reason:

Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.

Choice B reason:

Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.

Choice C reason:

Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.

Choice D reason:

Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.

A. Paper tape. B. Small gauze pad. C. Sterile gloves. D. Exam gloves. E. Three mL syringe.

Correct Answer is ["A","B","D"]

Explanation

The correct answer is: a. Paper tape, b. Small gauze pad, and d. Exam gloves.

Choice A: Paper tape

Reason: Paper tape is used to secure the gauze pad over the site after the saline lock is removed. It is gentle on the skin and helps to keep the gauze in place, preventing any bleeding or infection at the site.

Choice B: Small gauze pad

Reason: A small gauze pad is essential to apply pressure to the site after the saline lock is removed. This helps to stop any bleeding and provides a clean, sterile covering for the site.

Choice C: Sterile gloves

Reason: Sterile gloves are not necessary for this procedure. Exam gloves are sufficient to maintain cleanliness and prevent infection during the removal of the saline lock.

Choice D: Exam gloves

Reason: Exam gloves are used to maintain hygiene and prevent infection during the procedure. They provide adequate protection for both the nurse and the patient.

Choice E: Three mL syringe

Reason: A three mL syringe is not required for the removal of a saline lock. Syringes are typically used for flushing the saline lock, not for its removal.

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In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is ["A","B","D"]

Explanation

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