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The critical care nurse is caring for a 1, 4, 5
client
with a subclavian central line
catheter. The
nurse knows that a specific
central-line
bundle was developed to reduce
the
client's risk for developing a
catheter-
related bloodstream infection
(CLABSI).
The interventions include which
essential
actions? Select all that apply.
1.
Strict hand washing
2.
Daily dressing change
3.
Betadine skin antisepsis
4.
Optimal catheter site selection
5.
Strict sterile technique with maximal
barrier
precautions during placement
6.
Infection control primary health care
provider as a member of the client's
health
care team
The nurse caring for a 2, 3, 4
Chinese-American
client plans to use communication
according to Chinese-American
cultural
,beliefs and practices. Which
techniques are
considered disrespectful in the
Chinese-
American's view of communication?
Select
all that apply.
1.
Sitting side-by-side
2.
Maintaining eye contact
3.
Closing the conversation abruptly
4.
Touching the opposite sex in public
5.
Allowing silent pauses during
conversation
he nurse is assigned to care for a 2, 5
client with
a diagnosis of detached retina.
Which
findings would indicate that
bleeding has
occurred as a result of retinal
detachment?
Select all that apply.
1.
Total loss of vision
2.
Vision may be cloudy
3.
A reddened conjunctiva
4.
A sudden sharp pain in the eye
5.
Complaints of a burst of black spots
or
,floaters
6.
Vision is clear straight ahead but not
to the
right
The nurse admits a client who has 1, 2, 3, 4, 6
seizure
precautions prescribed. The client
has a
seizure just after the nurse has
implemented the precautions. Which
actions should the nurse take? Select
all
that apply.
1.
Time the start and stop of the
seizure.
2.
Apply oxygen at 2L with nasal
cannula.
3.
Turn the client to the side and do not
restrain.
4.
Note the distinguishing
characteristics of
the seizure.
5.
Use a padded tongue blade to
avoid
tongue injury.
6.
Turn on the suction machine with oral
catheter.
, A primary health care provider 1
(PHCP) has
written a prescription for a
preoperative
client to have "enemas until clear."
The
nurse has administered three enemas
and
the client is still passing brown liquid
stool.
Which action should the nurse take
next?
1.
Notify the primary health care
provider.
2.
Continue to administer the enemas
until the
stool is clear.
3.
Encourage the client to drink clear
liquids
and administer another enema in 1
hour.
4.
Wait 30 minutes, check the client's
electrolyte levels, and then
administer
another enema.
The nurse reviews the client's health 1, 2, 5
record
and notes that based on Leopold's
maneuvers, the fetus is in a cephalic
presentation. Which findings while
performing Leopold's maneuvers
support
the identification of a cephalic
presentation? Select all that apply.
1.
Small parts are located on the left
side of
the uterus.