A nurse is caring for a client who has a peritoneal catheter that requires a dressing change.
Identify the sequence of actions the nurse should take.
Apply precut gauze pads to the site.
Create a sterile field.
Mask self and the client.
Cleanse the site with povidone-iodine.
Correct Answer : A,B,C,D,E
Choice E rationale
Removing the old dressing is the first step in a dressing change procedure. It must be done to visualize the site and assess for signs of infection or other complications. Proper removal also prevents contamination of the new dressing materials and allows for thorough cleansing of the area before a new dressing is applied, which is a critical step in maintaining aseptic technique.
Choice C rationale
Masking is a crucial step in maintaining a sterile field and preventing cross-contamination. Donning a mask protects the client from respiratory microorganisms of the nurse and protects the nurse from potential splashes or aerosolized particles from the client's catheter site. This step is performed after removing the old dressing but before creating the sterile field to minimize contamination risk.
Choice B rationale
Creating a sterile field is an essential step in preventing microbial contamination of the catheter site. A sterile field provides a clean, controlled environment for sterile supplies and equipment. The nurse must establish this field after donning a mask and before touching any sterile items to ensure that the materials used for the dressing change remain free of pathogens.
Choice D rationale
Cleansing the site with an antiseptic solution like povidone-iodine is a critical step to reduce the bacterial load and prevent infection. This action is performed after the sterile field is established but before applying the new dressing. The antiseptic solution disrupts microbial cell membranes and inactivates enzymes, thus reducing the risk of a catheter-associated bloodstream infection.
Choice A rationale
Applying precut gauze pads is the final step in the sequence. These pads provide a protective barrier over the cleansed site, absorb any drainage, and prevent environmental microorganisms from entering the site. This action is taken after the site has been thoroughly cleaned and dried, ensuring that the new dressing remains sterile and effective. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
The telephone number is considered a reliable client identifier because it is unique to the individual and typically part of their personal health record. Using multiple identifiers, such as the telephone number in conjunction with the client's name and date of birth, is a critical safety measure to prevent medication errors and ensure the right medication is administered to the right client. This process, known as the "two-identifier rule," is a cornerstone of client safety protocols and aligns with guidelines from organizations like The Joint Commission
Correct Answer is C
Explanation
Choice A rationale
Losartan is an angiotensin II receptor blocker (ARB) which works by preventing angiotensin II from binding to its receptors in vascular smooth muscle, thereby causing vasodilation and lowering blood pressure. Hypertension is the condition losartan is prescribed to treat, not an adverse effect, because its mechanism directly counteracts the vasoconstrictive effects of angiotensin II. The intended therapeutic effect is a reduction in systemic vascular resistance and blood pressure.
Choice B rationale
Double vision, also known as diplopia, is not a recognized common or significant adverse effect of losartan. The mechanism of action of losartan primarily targets the renin-angiotensin-aldosterone system (RAAS), influencing blood pressure regulation and fluid balance, not directly affecting the central nervous system or ocular motor function. This symptom would be more indicative of neurological or ophthalmological issues unrelated to the medication's primary action.
Choice C rationale
Dizziness is a common adverse effect of losartan. This is a direct consequence of its therapeutic action, which is to lower blood pressure. The resulting vasodilation and reduced blood pressure can lead to orthostatic hypotension, causing feelings of lightheadedness or dizziness, especially when a person changes positions, like standing up. The brain's reduced perfusion pressure triggers this sensation as a physiological response.
Choice D rationale
Hyperactivity is not an expected adverse effect of losartan. The medication primarily affects the cardiovascular system by modulating the RAAS to lower blood pressure. It does not have known stimulant properties that would lead to increased energy, restlessness, or hyperactivity. Such a finding would likely be attributed to other factors or a different underlying condition, not the pharmacological action of this medication. *.
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