Author Question: A nurse is changing a peripheral venous access dressing for a client. Which of the following is a ... (Read 19 times)

JGIBBSON · **on:** Jul 23, 2018

A nurse is changing a peripheral venous access dressing for a client. Which of the following is a recommended step in this procedure?

A) Observe clean technique to minimize the possibility of contamination.
B) Cleanse site thoroughly with sterile saline, or according to facility policy.
C) Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.
D) Wipe or blot the site dry and allow to dry completely before covering.

Question 2

A nurse is caring for a client with dehydration. Which of the following signs is observed in a client with dehydration? Select all that apply.

A) Decreased skin turgor over sternum
B) Decreased blood pressure
C) Low urine output
D) Increased pulse rate
E) Increased respiratory rate

Shshxj · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: C
The nurse should do the following: observe meticulous aseptic technique to minimize the possibility of contamination; cleanse site with an antiseptic solution, such as chlorhexidine, or according to facility policy; press applicator against the skin and apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. The nurse should not wipe or blot, and should allow to dry completely before reapplying dressing.

Answer to Question 2

Ans: A, B, C
The nurse should note decreased skin turgor, decreased blood pressure, and low urine output in a client with dehydration. The client's pulse and respiratory rate would decrease, instead of increase, with dehydration.