A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Instilling an ophthalmic ointment for a client who has a corneal abrasion

Inserting an NG tube for a client who needs continuous enteral feedings

Changing a central venous catheter dressing for a client who is receiving IV therapy

Administering an IM injection to a client who has bacterial pneumonia

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Changing a central venous catheter dressing for a client who is receiving IV therapy. Choice A rationale: Instilling ophthalmic ointment typically does not require sterile gloves. Clean technique is sufficient as long as proper hand hygiene is performed to prevent infection. Choice B rationale: Inserting an NG tube requires clean technique, not sterile. The procedure is performed through the nasal passage and esophagus, which are not sterile environments. Choice C rationale: Changing a central venous catheter dressing requires sterile gloves to prevent introducing infection into the bloodstream. Central lines are a direct pathway to the central circulation, making aseptic technique critical to prevent serious infections such as bloodstream infections. Choice D rationale: Administering an IM injection requires clean technique. The skin is cleaned with an antiseptic wipe before the injection, but sterile gloves are not necessary for this procedure.

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Correct Answer is D

Explanation

The correct answer is choice d. Measure the client’s abdominal girth daily.

Choice A rationale:

Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.

Choice B rationale:

Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.

Choice C rationale:

Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.

Choice D rationale:

Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.

A. "Repeat the dose if your child vomits within 1 hour after taking the medication." B. "You can add the medication to a half-cup of your child's favorited juice." C. "Have your child drink a small glass of water after swallowing the medication." D. "Limit your child's potassium intake while she is taking this medication."

Correct Answer is C

Explanation

Choice A reason:

"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.

Choice B reason:

"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.

Choice C reason:

"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.

Choice D reason:

"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.

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A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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