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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care.

Which of the following interventions should the nurse plan to implement? Select all that apply.

Give antihypertensive medication.

Perform a vaginal examination every 12 hr.

Provide a low-stimulation environment.

Administer betamethasone.

Obtain a 24-hr urine specimen.

Monitor intake and output hourly.

Maintain bed rest.

Answer and Explanation

Correct Answer : A,E,F

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Correct Answer is C

Explanation

Changing a central venous catheter dressing for a client who is receiving IV therapy. Sterile gloves are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected. A central venous catheter is inserted into a large vein near the heart and can be a source of infection if not handled properly. Changing the dressing requires sterile gloves to prevent contamination of the catheter site and the bloodstream.

A. Contact the family regarding the client's condition. B. Notify risk management. C. Inform the transferring agency of the client's condition. D. Privately interview the client about the injuries.

Correct Answer is D

Explanation

The correct answer is choice d. Privately interview the client about the injuries.

Choice A rationale:

Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.

Choice B rationale:

Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.

Choice C rationale:

Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.

Choice D rationale:

Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care.

Which of the following interventions should the nurse plan to implement? Select all that apply.