How should excess hair at the site of an I.V. catheter insertion be treated?

Correct Answer: C

Rationale: The correct answer is C: Clipping the hair in the area. This is the best option as it removes excess hair without the risk of causing microabrasions or skin irritation, which could increase the risk of infection. Clipping is less traumatic to the skin compared to shaving, which can cause microcuts. Leaving the hair intact can make it difficult to properly clean and maintain the site. Using a depilatory is not recommended as it can cause chemical irritation and is unnecessary for this purpose. Overall, clipping the hair in the area is the most appropriate and safe method for managing excess hair at an I.V. catheter insertion site.

Correct Answer: A

Rationale: The correct initial response is A: Explain the risks of not having the surgery. This is crucial to ensure the client fully understands the consequences of refusing the surgery. It allows the nurse to address any concerns or misconceptions the client may have, enabling an informed decision-making process. Notifying the physician immediately (B) may be necessary but should follow after attempting to provide education. Notifying the nursing supervisor (C) is not the priority in this situation. Recording the client’s refusal in the nurses’ notes (D) is important but should not be the first action taken.

Correct Answer: D

Rationale: The correct answer is D: Counselor. The nurse assumes the role of counselor when guiding a client in making healthcare decisions by providing emotional support, helping the client explore options, and facilitating informed decision-making. A leader typically involves taking charge or directing a group, which may not always be appropriate in this context. An advocate focuses on promoting the client's rights and best interests but may not necessarily provide the counseling aspect. A liaison acts as a link or intermediary between the client and other healthcare providers, which is different from providing direct counseling and support.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. The cuff size should be appropriate to ensure accurate readings. 2. A cuff that is too small can result in falsely elevated readings. 3. A cuff that is too large can lead to falsely low readings. 4. Placing the cuff 1 cm above the brachial artery ensures proper placement for accurate measurements. Other Choices: A: The nurse should make sure that the cuff is deflated fully - Incorrect. The cuff should be inflated fully for accurate readings. B: then immediately start the second reading for the same client - Incorrect. It is important to wait a few minutes between readings to allow the blood vessels to recover. C: The nurse should release the valve carefully so that the pressure decreases at the rate of 2-3 mmHg per second - Incorrect. The pressure should be released at a steady rate, not specific to 2-3 mmHg per second.

Correct Answer: B

Rationale: The correct answer is B: Remove dead skin cells and debris. Wet-to-dry dressings help in debriding the wound by promoting the removal of dead tissue and debris when the dressing is changed. This process aids in creating a clean wound bed, which is essential for proper wound healing. The other choices are incorrect because wet-to-dry dressings are not primarily used to prevent wound infections (A), absorb blood and drainage (C), or protect the skin from injury (D). These functions may be achieved through other types of dressings or wound care methods.