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NurseDive Free Nursing Practice Question
A newly hired nurse is preparing to remove a client's IV catheter. Which of the following actions should the nurse take?
A. Ask an assistive personnel (AP) to verbalize the steps for removing an IV catheter.
While an assistive personnel (AP) might assist with some tasks, they are not typically responsible for providing detailed procedural guidance on medical tasks. The nurse should seek guidance from established protocols and trained professionals.
B. Research how to remove an IV catheter from the internet.
While online resources can be helpful, they might not reflect the specific protocols or best practices of the facility. It's crucial to follow the facility’s policies and procedures to ensure consistency and compliance with organizational standards.
C. Find an article in a nursing journal that is less than 5 years old on how to remove IV catheters.
While reviewing current literature is beneficial for understanding best practices, the most immediate and relevant source of information is the facility's own policies and procedures. These documents will reflect the specific protocols that the facility requires.
D. Review the facility's policies and procedures manual about removing IV catheters.
Reviewing the facility's policies and procedures manual ensures that the nurse follows the specific guidelines and standards set by the institution. This approach aligns with organizational requirements and helps ensure that the procedure is performed correctly and safely within the context of the facility’s protocols.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med surg exam 1A Proctored Exam. Take the full exam now
Full Explanation
A. While an assistive personnel (AP) might assist with some tasks, they are not typically responsible for providing detailed procedural guidance on medical tasks. The nurse should seek guidance from established protocols and trained professionals.
B. While online resources can be helpful, they might not reflect the specific protocols or best practices of the facility. It's crucial to follow the facility’s policies and procedures to ensure consistency and compliance with organizational standards.
C. While reviewing current literature is beneficial for understanding best practices, the most immediate and relevant source of information is the facility's own policies and procedures. These documents will reflect the specific protocols that the facility requires.
D. Reviewing the facility's policies and procedures manual ensures that the nurse follows the specific guidelines and standards set by the institution. This approach aligns with organizational requirements and helps ensure that the procedure is performed correctly and safely within the context of the facility’s protocols.
Similar Questions
A nurse is assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
A. Oliguria
B. Peripheral edema
Peripheral edema refers to the swelling of the extremities, such as the hands, feet, and ankles, which is a common manifestation of hypervolemia. It occurs due to an excessive accumulation of fluid in the interstitial spaces. Oliguria, which refers to decreased urine output, is more commonly associated with conditions like dehydration or hypovolemia (fluid volume deficit). In hypervolemia, the kidneys may still be able to produce an adequate amount of urine. Hypotension, or low blood pressure, is not commonly seen in hypervolemia. Increased fluid volume leads to increased blood volume, which can result in elevated blood pressure rather than hypotension. Bradycardia, a slower heart rate, is not typically associated with hypervolemia. In fact, hypervolemia can sometimes lead to an increased heart rate as the heart works harder to pump the excess fluid throughout the body.
C. Hypotension
D. Bradycardia
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
The pH of 7.3 indicates acidemia (a lower-than-normal blood pH), and the PaCO2 of 50 mm Hg indicates hypercapnia (an elevated level of carbon dioxide in the blood). Together, these findings indicate respiratory acidosis, which is an acid-base imbalance that occurs when the lungs are unable to remove enough carbon dioxide from the body, leading to an accumulation of carbonic acid in the blood. Metabolic acidosis, on the other hand, is an acid-base imbalance that occurs due to an excess of acid or a loss of bicarbonate in the body, resulting in a low pH and a low bicarbonate level. Respiratory alkalosis is an acid-base imbalance that occurs when there is a decreased level of carbon dioxide in the blood, resulting in an elevated blood pH. Metabolic alkalosis is an acid-base imbalance that occurs due to an excess of bicarbonate in the body, resulting in an elevated pH and a high bicarbonate level.
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?
A. Lethargy
Lethargy and/or altered mental status: Respiratory acidosis can lead to a decrease in the pH of the blood, resulting in acidemia. Acidemia affects the central nervous system and can cause lethargy, confusion, and other alterations in mental status. Other findings associated with respiratory acidosis may include: Headache Tachycardia (increased heart rate) Hypoventilation (shallow or slow breathing) Shortness of breath or difficulty breathing Cyanosis (bluish discoloration of the skin and mucous membranes due to decreased oxygenation) Decreased blood pressure Abdominal pain, dry skin, and numbness of fingers are not typically associated with respiratory acidosis. These findings may be more indicative of other conditions or imbalances.
B. Abdominal pain
C. Dry skin
D. Numbness of fingers