A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

Place the client in Trendelenburg position during the procedure.

Instruct the client to maintain a full bladder for the procedure.

Administer a tocolytic 30 min before the procedure.

Monitor the fetal heart rate throughout the procedure.

Answer and Explanation

The Correct Answer is D

A. Place the client in Trendelenburg position during the procedure – Incorrect, as amniocentesis is typically performed with the client in a supine position.

B. Instruct the client to maintain a full bladder for the procedure – This is required for an early pregnancy amniocentesis (before 20 weeks), but for later procedures, the bladder should be empty.

C. Administer a tocolytic 30 min before the procedure – Not routinely necessary unless the client is at risk for preterm labor.

D. Monitor the fetal heart rate throughout the procedure – Correct, as amniocentesis carries a risk of fetal distress, and continuous monitoring ensures immediate detection of complications.

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Correct Answer is C

Explanation

A. Data comparison should be done after establishing the standards and collecting data.

B. While data collection is important, the first step is to determine what the accepted hand hygiene standards are.

C. This is the correct answer. The first step in an audit process is to determine the accepted hand hygiene standards to provide a basis for evaluation.

D. Corrective measures should only be taken after data has been collected and analyzed.

A. Choose the client's dominant arm for IV access whenever possible. B. Initiate IV access on the palmar side of the client's wrist. C. Select a site proximal to previous venipuncture sites. D. Insert a larger gauge IV catheter to prevent phlebitis.

Correct Answer is C

Explanation

A. The non-dominant arm should be used when possible to minimize interference with daily activities.

B. The palmar side of the wrist is highly sensitive and should be avoided due to the risk of discomfort and nerve injury.

C. This is the correct answer. The nurse should select a site proximal to previous venipuncture sites to maintain vein integrity and avoid complications such as infiltration or phlebitis.

D. Using a larger gauge catheter increases the risk of phlebitis rather than preventing it.

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A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols. Which of the following steps should the task force take first?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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