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A nurse is assisting with the care of the client

Exhibits

Complete the following sentence by using the list of options.

The nurse should first plan to 

followed by.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Correct answer: The nurse should first plan to determine if the nasogastric tube is in the correct position, followed by monitoring the client's electrolyte levels.

Determine if the nasogastric tube is in the correct position: It is crucial to ensure the nasogastric tube is correctly positioned to allow for proper drainage and to prevent complications such as aspiration.

Monitor the client's electrolyte levels: Given the client’s abnormal laboratory results (low sodium and potassium levels), it's important to closely monitor electrolytes to prevent further imbalances and complications.


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Related Questions

Correct Answer is A

Explanation

A. Initiate fall precautions: Fall precautions are essential for clients with aspiration pneumonia and hypoxia as they may be disoriented or have impaired oxygenation, increasing the risk of falls.
B. Applying petroleum jelly to the client's nares is not appropriate in this case, as it does not address the client's aspiration pneumonia or hypoxia.
C. Implementing contact precautions is not necessary for aspiration pneumonia unless there is a specific infection that requires isolation precautions (e.g., bacterial infections).
D. Maintaining the client in a supine position can worsen hypoxia and aspiration, as it can facilitate fluid or food moving into the lungs. The client should be maintained in an upright position to promote better oxygenation and prevent aspiration.

Correct Answer is B,E,C,A,D

Explanation

Correct order:

  1. Perform hand hygiene.
  2. Remove the dressing and tape from the venipuncture site.
  3. Clamp the IV tubing.
  4. Apply pressure to the venipuncture site with sterile gauze.
  5. Withdraw the catheter from the client's vein.

Rationale:

  1. Hand hygiene is the first step to prevent infection before touching any equipment or the client.
  2. Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
  3. Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
  4. Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
  5. Withdrawing the catheter should be the final step to complete the procedure.

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