A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?

Change the secondary IV infusion set twice weekly.

Change a continuously infusing IV bag after 48 hr.

Change the primary IV infusion set every 96 hr.

Change the extension tubing once per week.

Answer and Explanation

The Correct Answer is C

A. Change the secondary IV infusion set twice weekly: Secondary IV sets, such as piggyback infusions, should generally be changed every 24 hours to reduce the risk of contamination and infection. Changing them twice weekly would not maintain proper asepsis.

B. Change a continuously infusing IV bag after 48 hr: Continuous IV bags should be replaced at least every 24 hours to prevent bacterial growth. Waiting 48 hours increases the risk of microbial contamination and bloodstream infections.

C. Change the primary IV infusion set every 96 hr: Changing the primary IV infusion set every 96 hours (4 days) aligns with standard infection-control guidelines. This interval helps maintain asepsis while minimizing the risk of IV-related infections.

D. Change the extension tubing once per week: Extension tubing connected to the IV line should be changed more frequently, typically every 72 to 96 hours, to prevent contamination. Once per week is too infrequent and increases infection risk.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Place a vibrating tuning fork on the top of the client's head: This describes the Weber test, which assesses lateralization of sound to determine conductive versus sensorineural hearing loss.

B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal: In the Rinne test, the nurse compares bone conduction and air conduction. After placing the fork on the mastoid bone, it is moved in front of the ear canal to test air conduction, which should normally be longer than bone conduction.

C. Activate a tuning fork and place the prongs on the client's occipital area: Placing the tuning fork on the occipital bone is not part of any standard hearing assessment test. It would not yield useful information about bone or air conduction.

D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse: This describes the whisper test, a screening tool for gross hearing acuity. It is not related to the Rinne test procedure.

A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in). B. Auscultate each of the four quadrants for 5 min before determining sounds are absent. C. Percuss each of the four quadrants of the abdomen. D. Inspect each of the four quadrants for abdominal distention.

Correct Answer is B

Explanation

A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in): Palpation assesses tenderness, masses, or organ enlargement but does not evaluate peristalsis. Palpating too soon postoperatively can also cause discomfort or disrupt healing.

B. Auscultate each of the four quadrants for 5 min before determining sounds are absent: Bowel sounds indicate peristalsis, and a full 5 minutes of auscultation is required before concluding they are absent, especially after abdominal surgery where bowel activity may be reduced.

C. Percuss each of the four quadrants of the abdomen: Percussion evaluates the presence of fluid, gas, or organ borders but does not provide information about bowel motility. It is useful for assessing distention but not peristalsis.

D. Inspect each of the four quadrants for abdominal distention: Inspection identifies visible abnormalities such as distention, scars, or pulsations. While distention may suggest reduced peristalsis, visual inspection alone does not confirm bowel activity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?

Correct Answer is B

Explanation

A nurse on the medical-surgical unit is planning care for a male client after reviewing their electronic health record (EHR). Exhibits Which of the following provider prescriptions should the nurse anticipate receiving to implement in the client's plan of care? Select 3 provider prescriptions.

A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles should the nurse plan to insert the needle?

A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

A nurse is assessing a client who has hypokalemia. Which of the following findings should the nurse expect?

A school nurse is teaching a group of guardians about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?