A nurse is preparing to administer medication to a client.
Which of the following identifiers should the nurse use to identify the client?

Choice A rationale

Chilling the lavage fluid causes vasoconstriction of the gastric blood vessels, which helps to slow or stop the bleeding. The cold temperature directly constricts the capillaries and arterioles in the stomach lining, reducing blood flow to the bleeding site. This action is a primary goal of gastric lavage in cases of upper gastrointestinal hemorrhage.

Choice B rationale

Positioning the client on their left side is the appropriate action. This position allows the lavage fluid to pool in the greater curvature of the stomach, where it can be most effective at washing over the bleeding site. Placing the client on their right side would cause the fluid to quickly pass into the duodenum, which is less effective for gastric lavage.

Choice C rationale

Gastric lavage is performed to remove blood and clots from the stomach. The procedure involves instilling a fluid, typically saline, and then withdrawing it. The nurse continues this process, manually withdrawing the fluid, until the return fluid is clear or only slightly pink, which indicates that the bleeding has been controlled or significantly reduced.

Choice D rationale

A large-bore NG tube (16-18 French or larger) is preferred for gastric lavage in cases of upper gastrointestinal bleeding. A large-bore tube is necessary to effectively remove blood clots and viscous fluid from the stomach. A small-bore tube would easily become occluded by clots, rendering the lavage procedure ineffective. *.

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. *.