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    ATI N480 Advanced Med Surg proctored Exam_

    A nurse is assessing a client. Which of the following actions should the nurse take?

    Explanation & Rationale

    Choice A reason: Obtaining blood glucose every 12 hours is appropriate for stable diabetic patients but not a universal nursing action without context. Specific conditions like DKA require more frequent monitoring, making this less broadly applicable than maintaining IV site integrity to prevent infection. Choice B reason: Changing IV tubing every 24 hours is not standard, as guidelines recommend every 72-96 hours unless contaminated. Frequent changes increase costs and disruption without clear benefit, making this less appropriate than maintaining IV site dressings to ensure safety and infection control. Choice C reason: Changing the IV site dressing every 4 days aligns with infection prevention guidelines, ensuring a clean, secure site to reduce catheter-related bloodstream infections. This is a standard nursing action for clients with IV access, making it the most appropriate intervention in this context. Choice D reason: Weighing the client every other day is relevant for specific conditions like heart failure but not a universal nursing action. Maintaining IV site dressings is a broader priority to prevent infections, applicable to most clients with IV access, making this less critical.

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