The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)
Small gauze pad.
Paper tape.
Three mL syringe.
Exam gloves.
Sterile gloves.
Correct Answer : A,B,D
These are the correct supplies for the PN to gather because they are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site and secure it with paper tape after removing the saline lock.
C. A three mL syringe is not needed to remove a saline lock and may cause confusion or harm if used incorrectly.
E. Sterile gloves are not needed to remove a saline lock and may be wasteful or unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Red welts widespread over the chest.
Choice A rationale:
Ulceration on the corner of the upper lip does not indicate a need for loratadine administration. Loratadine is an antihistamine commonly used to relieve symptoms of allergies such as sneezing, runny nose, and itchy or watery eyes. Ulceration on the lip is not associated with an allergic reaction.
Choice B rationale:
Ecchymosis and petechiae on the legs are not related to the need for loratadine. These findings suggest potential bleeding or clotting disorders, and loratadine does not address such issues.
Choice C rationale:
Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.
Choice D rationale:
Red papules and pustules on the face are unlikely to be treated with loratadine. These skin manifestations may be related to various dermatological conditions, but not necessarily allergic reactions that loratadine is primarily used to manage.
Correct Answer is C
Explanation
This is the best action for the PN to take because it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.
A. Documenting the client's loss of memory in the record is not enough and does not address the client's needs.
B. Notifying the family of the change in the client's condition is not a priority and may not be necessary if the confusion is temporary or reversible.
D. Encouraging the client to rest during the day is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.
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