A nurse is evaluating an assistive personnel (AP) who is changing a client's bed linens. Which of the following actions by the AP demonstrates medical asepsis?

Holds linens close to the body

Shakes soiled linens before placing them in the hamper

Puts unneeded clean linens in the hamper

Places soiled linens on the floor

Answer and Explanation

The Correct Answer is A

A. Holds linens close to the body: Holding linens close to the body reduces the risk of contamination and ensures that the linens do not touch potentially unclean surfaces. This practice helps maintain medical asepsis by preventing the spread of microorganisms.

B. Shakes soiled linens before placing them in the hamper: Shaking soiled linens can cause microorganisms to become airborne and spread. To maintain asepsis, linens should be handled gently and placed directly into the hamper without shaking.

C. Puts unneeded clean linens in the hamper: Clean linens should not be placed in the hamper as they could become contaminated. Clean linens should be stored in a clean area to maintain their aseptic state until needed.

D. Places soiled linens on the floor: Placing soiled linens on the floor introduces the risk of contamination, as the floor is not considered a clean surface. Soiled linens should be placed directly into a designated container to maintain medical asepsis.

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Correct Answer is B

Explanation

A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.

B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.

C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.

D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.

A. "You should try putting the baby in a carrier so you can take a walk when they start crying.” B. "Tell me more about what is going on when the baby starts crying.” C. "Many parents have told me it gets better when the baby is about 3 months old.” D. "As a new parent, you should be enjoying your time with the baby.”

Correct Answer is B

Explanation

A. "You should try putting the baby in a carrier so you can take a walk when they start crying.": This response may not address the client's emotional frustration. It's important to first listen and understand the full context before offering advice.

B. "Tell me more about what is going on when the baby starts crying.": This response shows empathy and invites the client to share more about their experience. It allows the nurse to better understand the situation and provide support or guidance tailored to the client’s concerns.

C. "Many parents have told me it gets better when the baby is about 3 months old.": It's important to explore the client’s current experience and feelings rather than assuming their situation will improve without validating their concerns.

D. "As a new parent, you should be enjoying your time with the baby.": This statement may come across as judgmental as it implies the client should be feeling something different. It is important to acknowledge and validate the client's feelings.

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A nurse is evaluating an assistive personnel (AP) who is changing a client's bed linens. Which of the following actions by the AP demonstrates medical asepsis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intravenous fluids. The nurse notes the client's skin around their peripheral IV site is taut and edematous. Which of the following complications is the client experiencing?

Correct Answer is B

Explanation

A nurse in a postpartum clinic is caring for a client who has returned for their 6-week postpartum visit. The client states emphatically, "I hate when the baby cries, and I can't get them to stop." Which of the following statements should the nurse respond with?

Correct Answer is B

Explanation

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