Review HESI RN Exit Exam IV

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HESI RN Exit Exam IV

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Question 1:

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A. Serum albumin. B. Neutrophil count. C. Serum blood glucose (BG) level. D. Hematocrit.

Answer and Explanation

Choice A:

Although low serum albumin levels can impact wound healing, they are not directly related to the presence of purulent drainage.

Choice B:

Neutrophils are a type of white blood cell involved in the body's immune response, particularly against bacterial infections. An elevated neutrophil count (neutrophilia) can indicate an acute infection or inflammation, including in wounds.

Choice C:

High blood glucose levels can predispose the client to infections, including wound infections. While it's important to monitor blood glucose levels, it is less directly relevant to the immediate concern of purulent drainage from the burn wound.

Choice D:

Hematocrit measures the proportion of red blood cells in the blood and is used to assess hydration status and oxygen-carrying capacity. In burn patients, changes in hematocrit can indicate fluid shifts and potential dehydration. Fluid shifts and dehydration can influence wound healing and overall patient condition but are not directly related to the presence of purulent drainage.

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Question 2:

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

A. Soak feet daily in hot water no longer than 10 minutes. B. Include no more than 1-2 alcoholic beverages in diet per day. C. Remember exercise will not affect blood glucose levels. D. Keep any wounds covered with an antibiotic ointment.

Answer and Explanation

Choice A:

Correct choice is B
Rationale
A This statement is incorrect for diabetes management. People with diabetes should avoid soaking their feet in hot water, as it can lead to burns and skin damage, which is particularly risky due to potential nerve damage (neuropathy) and poor circulation common in diabetes.

Choice B:

This statement demonstrates good understanding. Alcohol can affect blood sugar levels and should be consumed in moderation by people with diabetes. Limiting intake to 1-2 drinks per day (following healthcare provider's advice) is generally recommended to minimize the impact on blood sugar levels and overall health.

Choice C:

Exercise is crucial for managing blood glucose levels in people with diabetes. Physical activity helps muscles use glucose for energy and can lower blood sugar levels. Understanding the importance of regular exercise is key for effective diabetes management.

Choice D:

While keeping wounds covered is generally good advice to prevent infection, using antibiotic ointment on every wound is not necessary unless specifically advised by a healthcare professional. Proper wound care, including cleaning with mild soap and water, keeping the wound clean and dry, and seeking medical attention for any signs of infection

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Question 3:

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

A. Leave the client's room and return later in the day. B. Refer client to the social worker for support therapy. C. Encourage client to implement relaxation techniques. D. Explain that insulin is a life-saving drug for the client.

Answer and Explanation

Choice A:

This allows the client time to process their emotions. A diagnosis with a chronic illness can be overwhelming.

Choice B:

Referring the client to a social worker for support therapy is a good idea for ongoing emotional support and counseling. However, at this moment, the client might need immediate assistance

Choice C:

While relaxation techniques can be helpful in managing stress and anxiety, they might not address the immediate need for insulin administration education.

Choice D:

Explaining the importance of insulin, is crucial, but it may not be effective if the client is not in a receptive state.

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Question 4:

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

A. The pressure dressing at right femoral area is moist and oozing blood. B. Pulse distal to the femoral artery is weaker on left foot than right foot. C. Right foot is cool to the touch and appears pale and blanched. D. Blood pressure trend is downward and pulse is rapid and irregular.

Answer and Explanation

Choice A:

While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

Choice B:

This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

Choice C:

This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

Choice D:

These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

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Question 5:

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

A. Notify information services department of the situation. B. Print electronic medical record (EMR) from backup server. C. Wait for notification that the system has been rebooted. D. Identify information as late entry in the record.

Answer and Explanation

Choice A:

Informing the information services department allows them to be aware of the issue promptly. They can then investigate the cause of the system failure and initiate appropriate measures to restore the system. It's important to involve IT professionals who are responsible for maintaining and troubleshooting the computer system.

Choice B:

While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.

Choice C:

Correct choice is A
Rationale

Choice D:

Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.

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Question 6:

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

A. Monitor blood glucose level. B. Maintain strict intake and output. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Answer and Explanation

Choice A:

Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

Choice B:

Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

Choice C:

Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

Choice D:

Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Question 7:

A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

A. Fall at home as reason for admission. B. Currently prescribed medications. C. Increasing confusion of the client. D. Client's healthcare power of attorney.

Answer and Explanation

Choice A:

While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.

Choice B:

Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.

Choice C:

This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.

Choice D:

While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.

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Question 8:

A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client reports pain at the right groin insertion site. Which action should the nurse implement?

A. Assess distal lower extremity capillary refill. B. Check femoral site for hematoma formation. C. Evaluate the integrity of the IV insertion site. D. D Stimulate the client to take deep breaths.

Answer and Explanation

Choice A:

This action involves assessing the capillary refill of the lower extremity distal to the femoral site. It helps in evaluating peripheral perfusion and circulation to ensure there is no compromise to blood flow. This is important because decreased capillary refill could indicate impaired circulation, possibly due to arterial occlusion or hematoma formation.

Choice B:

Checking the femoral insertion site for hematoma formation is crucial after a cardiac catheterization. Hematomas can develop due to bleeding from the femoral artery puncture site, especially if the client is receiving anticoagulant therapy like heparin. A hematoma can compress surrounding structures, potentially causing pain and compromising circulation.

Choice C:

While it's important to assess the integrity of IV insertion sites, in this scenario, the primary concern is the groin insertion site used for cardiac catheterization. The IV insertion sites should be assessed regularly for signs of infiltration, phlebitis, or infection, but this should not take precedence over assessing the femoral insertion site for complications related to the procedure.

Choice D:

Deep breathing exercises are important for preventing respiratory complications such as atelectasis and pneumonia, especially in clients who are sedated and immobilized. However, in the context of acute pain at the femoral insertion site post-cardiac catheterization, assessing and addressing potential complications related to the procedure take priority.

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Question 9:

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

A. Outreach for support group information. B. Domestic violence assistance. C. Blood pressure screening. D. Immunizations that are available.

Answer and Explanation

Choice A:

While support groups are important for individuals dealing with chronic illnesses or specific health issues, they are not directly related to primary disease prevention. Support groups focus more on coping, emotional support, and managing existing conditions rather than preventing diseases.

Choice B:

Domestic violence assistance is crucial for community health and safety, but it is not typically categorized under primary disease prevention. Domestic violence is a social issue that requires interventions aimed at prevention and support for victims, rather than preventing diseases through health promotion and education.

Choice C:

Blood pressure screening is an example of a primary disease prevention activity. High blood pressure (hypertension) is a significant risk factor for cardiovascular diseases such as heart attack and stroke. By screening individuals for hypertension, nurses can identify those at risk early and provide education on lifestyle modifications or medical interventions to prevent cardiovascular disease.

Choice D:

Immunizations are a cornerstone of primary disease prevention. Vaccines prevent infectious diseases by stimulating the immune system to produce immunity against specific pathogens. Community outreach programs that educate the public about immunizations help increase vaccination rates, thereby reducing the incidence of vaccine-preventable diseases in the population.

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Question 10:

After years of struggling with weight management, a middle-aged adult client is evaluated for gastroplasty. The client has experienced difficulty with managing diabetes mellitus and hypertension, but is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?

A. Observe for signs of depression. B. Apply sequential compression stockings. C. Provide a wide variety of meal choices. D. Monitor for urinary incontinence.

Answer and Explanation

Choice A:

This intervention is crucial because bariatric surgery can have significant psychological impacts. Many individuals who undergo such procedures may experience changes in mood, body image issues, and emotional challenges. However, it is not a priority

Choice B:

Sequential compression stockings are used to prevent deep vein thrombosis (DVT) and promote circulation in clients undergoing surgery, particularly those with obesity who are at higher risk for venous thromboembolism. This intervention is important to prevent serious complications associated with immobility and surgery.

Choice C:

This option is not appropriate immediately after gastroplasty. Bariatric surgery, such as gastroplasty, typically involves restrictive procedures that limit the amount of food a person can consume. Providing a wide variety of meal choices contradicts the dietary restrictions and guidelines that are crucial for successful outcomes post-surgery.

Choice D:

While urinary incontinence can be a concern in some individuals, it is not directly related to bariatric surgery or the client's primary health concerns of obesity, diabetes mellitus, and hypertension. Monitoring for urinary incontinence may be important in other clinical contexts but is not a priority in the immediate postoperative period of gastroplasty.

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Question 11:

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

A. Lay prone for 24 hours after the procedure. B. Report any allergies to shellfish or iodine. C. Report any painful urination, blood in urine, or fever. D. Avoid strenuous activity and sports for at least 2 weeks.

Answer and Explanation

Choice A:

After a cystoscopy, clients typically do not need to lay prone (face down) for an extended period. They are usually allowed to resume normal activities fairly soon after the procedure.

Choice B:

This instruction is important because iodine-based contrast agents are commonly used during cystoscopy procedures to enhance visualization of the urinary tract. Clients with allergies to shellfish (due to potential cross-reactivity with iodine) or iodine itself should be identified to avoid allergic reactions. This allows the healthcare team to take appropriate precautions and possibly use alternative agents if needed.

Choice C:

This instruction is crucial for monitoring post-procedure complications. Painful urination, blood in urine (hematuria), and fever can indicate infection or other complications following a cystoscopy. Prompt reporting allows for early intervention and treatment if necessary.

Choice D:

This instruction is not typically necessary after a cystoscopy. Most clients can resume normal activities, including light exercise, shortly after the procedure. Avoiding strenuous activity for two weeks would be excessive and not aligned with typical post-cystoscopy recovery guidelines.

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Question 12:

A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

A. Avoid the consumption of wine, beer, and coffee. B. Substitute natural fruit juices for carbonated drinks. C. Encourage active range of motion to limit stiffness. D. Use electric heating pad when pain is at its worse.

Answer and Explanation

Choice A:

This instruction is relevant because alcohol, particularly beer and wine, can exacerbate gout symptoms due to their purine content, which can lead to increased uric acid levels in the blood. High uric acid levels can contribute to gouty arthritis flare-ups.

Choice B:

This instruction promotes a healthier dietary choice, as carbonated drinks often contain added sugars and contribute to excess calorie intake, which can contribute to obesity. However, fruit juices can also be high in sugars and should be consumed in moderation. Encouraging water as the primary beverage choice would be even better for weight loss and overall health.

Choice C:

This instruction is generally beneficial for maintaining joint mobility and preventing stiffness, which can be particularly important for someone experiencing pain in a weight-bearing joint like the ankle. However, if the pain is severe and acute, active range of motion exercises may need to be introduced gradually and under guidance to avoid exacerbating the condition.

Choice D:

Heat therapy can provide symptomatic relief for joint pain associated with conditions like gouty arthritis. However, it is important to ensure that heat is not applied during acute inflammation or gout flare-ups, as it can potentially worsen symptoms. Cold therapy may be more appropriate during active inflammation.

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Question 13:

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

A. Anticipate a stinging feeling during needle insertion. B. Prepare to sit forward with arms propped on a table. C. Expect a persistent cough after the procedure. D. Limit activity for a day or two after returning home.

Answer and Explanation

Choice A:

During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

Choice B:

The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

Choice C:

This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

Choice D:

This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

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Question 14:

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

A. Administer children's aspirin to help prevent inflammation. B. Keep the infant home from daycare for the next two days. C. Any level of fever is serious and should be reported right away. D. Apply a cool pack to the injection site to reduce discomfort.

Answer and Explanation

Choice A:

Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.

Choice B:

This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.

Choice C:

This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.

Choice D:

Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.

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Question 15:

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

A. Measure the vital signs. B. Assist to a high Fowler's position. C. Initiate deep breathing exercises. D. Auscultate breath sounds.

Answer and Explanation

Choice A:

Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.

Choice B:

Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.

Choice C:

While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priorityshould be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.

Choice D:

Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.

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Question 16:

A client with coronary artery disease (CAD) is admitted to the medical unit for testing. The client describes having had frequent episodes of angina over the last few days prior to admission. The client is now experiencing shortness of breath, nausea, and chest pressure. After obtaining the client's vital signs, which action should the nurse take next?

A. Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three. B. Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area. C. Count and record the number of premature ventricular contractions per minute. D. Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

Answer and Explanation

Choice A:

Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.

Choice B:

This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.

Choice C:

PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.

Choice D:

Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.

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Question 17:

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

A. Respiratory rate. B. Pain scale. C. Blood pressure. D. Level of consciousness.

Answer and Explanation

Choice A:

Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.

Choice B:

Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.

Choice C:

Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.

Choice D:

Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.

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Question 18:

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion?
(Enter numerical value only. If rounding is required, round to the nearest whole number.)

Answer and Explanation

Correct Answer: "21" gtt/min

Explanation

To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in
minutes.

For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours, with an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / (12 hours * 60 minutes/hour).

This simplifies to (15000 gtt) / (720 minutes), which equals approximately 20.83 gtt/min.

Therefore, the nurse should regulate the infusion to 21 gtt/min, rounding to the nearest whole
number.

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Question 19:

An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

A. Obtain thickening powder before providing any more fluids. B. Assist the spouse and carefully give the client small sips of water. C. Ask the spouse to stop and assess the client's swallowing reflex. D. Give the spouse a straw to help facilitate the client's drinking.

Answer and Explanation

Choice A:

Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

Choice B:

This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

Choice C:

This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

Choice D:

Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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Question 20:

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?

A. Instruct the nurse to use water with 5% dextrose (DW). B. Send an unlicensed assistive personnel to gather equipment. C. Prompt the nurse to apply povidone to the site. D. Direct the nurse to attach the luer-lock tip to the irrigation port.

Answer and Explanation

Choice A:

Using water with 5% dextrose (DW) is appropriate for irrigating certain types of catheters, especially those that require a non-saline solution to maintain patency. However, the choice of irrigation solution should be based on the specific type of catheter and the facility's policies. It does not directly address the immediate issue of the luer-lock syringe.

Choice B:

Sending someone else to gather equipment may be necessary in some situations but does not address the current issue of the nurse preparing to irrigate with a luer-lock tipped syringe. This option delays addressing the immediate concern.

Choice C:

Applying povidone (such as povidone-iodine solution) to the site is a step in the preparation for aseptic technique but does not address the specific issue of the syringe type or the irrigation process itself.

Choice D:

Luer-lock syringes are commonly used for irrigation purposes because they securely attach to irrigation ports, preventing accidental disconnection during the procedure. Directing the nurse to attach the luer-lock syringe ensures that the irrigation can be performed safely and effectively.

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