Which nursing activity is an example of using primary prevention in client care?

Screening for high blood pressure

Teaching preschoolers how to wash their hands correctly

Providing hospice care to a terminally ill client

Teaching a client how to self-administer insulin

Answer and Explanation

The Correct Answer is B

B. Teaching preschoolers how to wash their hands correctly is an example of primary prevention. By educating children on proper hand hygiene practices, nurses aim to reduce the spread of infections and promote good health habits. This activity focuses on preventing the transmission of infectious diseases and promoting overall wellness among children

A. Screening for high blood pressure is an example of secondary prevention rather than primary prevention. Secondary prevention involves early detection and treatment to halt or slow down the progress of a disease.

C. Providing hospice care is a form of palliative care that focuses on improving the quality of life for terminally ill clients and their families. It aims to provide comfort and support rather than preventing disease onset. Therefore, it does not fall under primary prevention but rather under supportive care for those with advanced illness.

D. Teaching a client how to self-administer insulin is an example of tertiary prevention. Tertiary prevention involves managing and reducing the impact of a disease that has already occurred. In this case, teaching self-administration of insulin helps manage diabetes, prevent complications, and promote optimal health outcomes for the client.

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Correct Answer is ["A","B","D"]

Explanation

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.

A. pump the cuff up again immediately before releasing it. B. use the client's radial pulse to determine how high to pump up the cuff C. obtain another cuff and take the blood pressure again in 30 minutes. D. release the cuff completely and wait two minutes before retaking the blood pressure.

Correct Answer is D

Explanation

D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.

A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.

B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.

However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.

C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.

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Which nursing activity is an example of using primary prevention in client care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["A","B","D"]

Explanation

The nurse, while obtaining the blood pressure reading of a client, is uncertain when the muffled sounds have ended. What is the nurse's best action at this time?

Correct Answer is D

Explanation

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