Share This Link

Changing a central venous catheter dressing for a client who is receiving IV therapy. Sterile gloves are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected. A central venous catheter is inserted into a large vein near the heart and can be a source of infection if not handled properly. Changing the dressing requires sterile gloves to prevent contamination of the catheter site and the bloodstream.

Interlace the fingers while rubbing hands together. This is one of the steps of performing a surgical hand scrub, which is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire. Interlacing the fingers helps to remove microorganisms from the spaces between the fingers and under the nails.

Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.

Believes his bad behavior is causing his brother's death. This is an example of magical thinking, which is common among school-age children (6 to 12 years old). Magical thinking is the belief that one's thoughts or actions can influence events or outcomes that are beyond one's control. School-age children may feel guilty or responsible for their sibling's illness or death and may try to bargain or change their behavior to prevent it.

This statement shows an understanding of the legal requirements for advance directives. Advance directives typically require notarization or witnessing to ensure their validity.

An advance directive is a legal document that allows a client to express their wishes regarding medical care in case they become incapacitated. The client should discuss this document with their family before signing it so that they are aware of the client's preferences and can respect them.

The other options are incorrect because the client can change their mind at any time, their partner does not need to be present, and an attorney does not need to notarize the document.

Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity, which is damage to the inner ear resulting in hearing loss or balance problems. The nurse should monitor the client's hearing and report any changes to the provider. The other options are incorrect because hypotension, hyperthermia, and slurred speech are not common adverse effects of gentamicin.

The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.

The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

Making funeral arrangements is an indication of hopelessness because it shows that the client has given up on the possibility of recovery or improvement. A decreased energy level, requesting a second opinion, and wanting to talk about the diagnosis are not necessarily signs of hopelessness, but rather normal reactions to a terminal illness.