The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

plastic insertion spike.

catheter adapter (hub).

drip chamber.

Y-site injection port.

roller clamp to regulate flow.

Answer and Explanation

Correct Answer : A,B,D

A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.

B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.

D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.

C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.

E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.

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Correct Answer is D

Explanation

D. This is the most appropriate goal for a client experiencing diarrhea. Diarrhea is characterized by loose or watery stools, and the goal of treatment is to restore normal stool consistency. This goal focuses on improving the symptoms and resolving the underlying cause of diarrhea, whether it's due to infection, dietary factors, or other reasons.

A. "Defecating regularly" does not necessarily imply improvement in diarrhea symptoms or resolution of the underlying cause. It is vague and does not provide a clear target related to diarrhea management.

B. Increasing ingestion of fruits may be beneficial for some individuals as fruits contain fiber and fluids that can help regulate bowel movements and maintain hydration. However, certain fruits high in fiber (e.g., apples, pears) may exacerbate diarrhea in some cases. This goal should be tailored based on the individual's tolerance and specific dietary needs.

C. This goal is not appropriate for managing diarrhea. Diarrhea leads to fluid loss and dehydration, so limiting fluid intake can worsen dehydration and electrolyte imbalances. Adequate fluid intake is crucial to replace lost fluids and maintain hydration during episodes of diarrhea.

A. The ulcer has thick dark eschar over the top B. Exposed bone/tendon is visible C. There is partial-thickness loss of dermis D. The wound extends into the subcutaneous tissue.

Correct Answer is B

Explanation

B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.

A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.

C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.

D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.

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The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

Which goal is appropriate for a client who is experiencing diarrhea? The client will:

Correct Answer is D

Explanation

The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?

Correct Answer is B

Explanation

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