Strategy: All answers are implementations.

Determine the outcome of each

answer choice. Is it desired?
(1) correctsterile articles should be dropped at a reasonable distance from the edge
of the sterile area
(2) sterile packs should be opened only as needed
(3) never reach an unsterile arm over a sterile field
(4) outside of a bottle containing sterile liquid is not considered to be sterile
83. A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
1.
2.
3.
4.

The client complains of pain during the inflow of the dialysate.

The client complains of constipation.
The dialysate outflow is cloudy.
There is blood-tinged fluid around the intra-abdominal catheter.

Strategy: Require an intervention indicates you are looking for a

complication.
(1) common complaint, moderate pain is frequently experienced as fluid is instilled
during first few exchanges
(2) common complaint due to inactivity, decreased nutrition, use of medications;
high-fiber diet and stool softeners help to prevent
(3) correctindicates peritonitis, also will see nausea and vomiting, anorexia,
abdominal pain, tenderness, rigidity
(4) caused by subcutaneous bleeding, common during first few exchanges
84. The nurse is observing care given to a client experiencing severe to
panic levels of anxiety. The nurse would intervene in which of the following
situations?
1. The staff maintains a calm manner when interacting with the client.
2. The staff attends to clients physical needs as necessary.
3. The staff helps the client identify thoughts or feelings that occurred prior to the
onset of the anxiety.
4. The staff assesses the clients need for medication or seclusion if other
interventions have failed to reduce anxiety.
Strategy: Nurse would intervene indicates that you are looking for an
inappropriate response.
(1) appropriate nursing action for this level of anxiety
(2) appropriate nursing action for this level of anxiety
(3) correctin this level of anxiety, client is unable to process thoughts and feelings
for problem solving
(4) appropriate nursing action for this level of anxiety