The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?
Coughs over the catheter site while cleansing the skin.
Wears one sterile glove when cleansing the insertion site.
Washes hands before opening the 4 by 4 dressing packet.
Pours antiseptic solution and sterile water on sterile dressings.
The Correct Answer is A
Choice A reason: Coughing over the catheter site while cleansing the skin is a behavior that indicates the client needs additional teaching. This action can introduce bacteria and other pathogens to the catheter site, increasing the risk of infection. Proper technique should include covering the mouth when coughing and ensuring the area remains as sterile as possible during the cleansing process. Educating the client on the importance of maintaining sterility and preventing contamination is crucial in peritoneal dialysis catheter care.
Choice B reason: Wearing only one sterile glove when cleansing the insertion site may not be ideal, but it does not necessarily indicate a lack of understanding or need for additional teaching. The main concern is ensuring the insertion site is cleaned properly. However, best practice would be to wear two sterile gloves to maintain sterility and reduce the risk of infection.
Choice C reason: Washing hands before opening the 4 by 4 dressing packet is a proper and essential technique in peritoneal dialysis catheter care. This action helps minimize the risk of infection by ensuring that the hands are clean before handling sterile supplies. This behavior does not indicate a need for additional teaching.
Choice D reason: Pouring antiseptic solution and sterile water on sterile dressings is an acceptable practice in peritoneal dialysis catheter care. This step helps disinfect the catheter site and maintain sterility. This behavior does not indicate a need for additional teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Driving a car is an activity that should be limited until after the first postoperative visit. Postoperative clients might experience discomfort, dizziness, or medication side effects that can impair their ability to drive safely. The stress and physical demands of driving can also affect the healing process, so it's important to avoid this activity until the healthcare provider gives clearance.
Choice B reason: Eating high-fiber foods is generally encouraged postoperatively to prevent constipation and ensure smooth bowel movements. There is no reason to limit high-fiber foods after a transurethral prostatectomy unless otherwise specified by the healthcare provider.
Choice C reason: Kegel exercises can help strengthen the pelvic floor muscles and are often recommended after prostate surgery to improve bladder control. However, it is important to follow the healthcare provider's guidance on when to start these exercises and how frequently they should be done.
Choice D reason: Walking around the house is a light activity that can aid in recovery by promoting circulation and preventing blood clots. It is usually recommended to start light activity soon after surgery, unless contraindicated by the healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Aldosterone is a hormone produced by the adrenal cortex that helps regulate sodium and potassium levels in the body. While aldosterone levels can indicate adrenal function, they are not as commonly used as cortisol levels in diagnosing adrenal cortex failure. Aldosterone regulation is also influenced by the renin-angiotensin-aldosterone system, making it a less direct indicator of overall adrenal cortex function compared to cortisol.
Choice B reason: Cortisol is a glucocorticoid hormone produced by the adrenal cortex and plays a vital role in regulating metabolism, immune response, and stress. Measuring cortisol levels is a primary method for assessing adrenal cortex function. Low cortisol levels can indicate adrenal insufficiency or failure, such as in conditions like Addison's disease. Evaluating cortisol levels provides a direct assessment of the adrenal gland’s ability to produce essential hormones necessary for the body's normal functioning.
Choice C reason: Thyroxine (T4) is a hormone produced by the thyroid gland, not the adrenal cortex. It plays a crucial role in regulating metabolism, growth, and development. While thyroxine levels are important for thyroid function assessment, they do not directly reflect the functioning of the adrenal gland. Therefore, thyroxine levels are not relevant in diagnosing adrenal cortex failure.
Choice D reason: Insulin is a hormone produced by the pancreas and is essential for regulating blood glucose levels. It is not related to the adrenal cortex. Monitoring insulin levels is important for diagnosing and managing diabetes mellitus but does not provide information about the functioning of the adrenal gland. Insulin levels are not used to assess adrenal cortex function.
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