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 A
Explanation
The injury description by the mother varies from the child's version.
Choice A rationale:
The practical nurse (PN) should note the significant indicator of possible child abuse, which is the discrepancy between the mother's description of the injury and the child's version. In cases of child abuse, perpetrators often provide inconsistent or conflicting explanations about how the injuries occurred, raising suspicion of maltreatment. This inconsistency can be a red flag for the PN to further assess the situation and, if necessary, report concerns to the appropriate authorities.
Choice B rationale:
While the child looking at the floor when answering questions might be a behavior worth noting, it alone is not a definitive indicator of child abuse. Children may exhibit various emotional responses for various reasons, and it requires further assessment to determine if there are signs of abuse.
Choice C rationale:
The healing of abrasions on the child's arms, legs, and chest does not necessarily indicate child abuse. Children are active and prone to minor injuries, which are a normal part of growing up. The PN should investigate further to determine the cause of the injuries.
Choice D rationale:
The mother describing in detail what she did for her injured child does not automatically suggest child abuse. It is essential for the PN to gather more information and conduct a comprehensive assessment before drawing any conclusions.
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side effects.
C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or affects the respiratory muscles.
D. Full facial flushing is not a priority finding and may be related to other factors such as vasodilation, inflammation, or medication side effects.
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