Nokea
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea. Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
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The nurse is using chlorhexidine to cleanse a vein site prior to inserting an IV catheter. While pressing the activated applicator on the skin, what should the nurse do next?
- A. Scrub the skin back and forth for 30 seconds.
- B. Scrub the skin in a circular motion for 10 seconds.
- C. Scrub until the solution is visually wet on the vein.
- D. Scrub until the skin appears to be dark brown in color.
Correct Answer: A
Rationale: A: Back-and-forth scrubbing for 30 seconds ensures effective antisepsis. B: Circular motion and 10 seconds are inadequate. C: Visual wetness is insufficient. D: Chlorhexidine is clear, causing no discoloration.
A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct Answer: D
Rationale: It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
The nurse assesses the hospitalized client and surveys the client's room. The client is Muslim. Which findings require the nurse's immediate attention to remove possible sources of infection? Select all that apply.
- A. A capped bottle of saline solution with a label stating that it was opened 10 hours ago.
- B. The abdominal dressing is saturated and seeping through to the client's gown and bed.
- C. An infusing intravenous (IV) tubing has no notation of the date when it was last changed.
- D. A container located in the bathroom that is labeled urine and has the client's initials.
- E. Opened packages of gauze sponges and abdominal pads sitting on the window sill.
- F. An uncovered cup of figs on the bedside table brought by a family member last evening.
Correct Answer: B,C,E,F
Rationale: B: A saturated dressing can harbor microorganisms, increasing infection risk. C: Unknown IV tubing change dates pose a risk as tubing should be changed every 72-96 hours. E: Opened dressing packages are contaminated and unsuitable for use. F: Uncovered food can attract microorganisms, requiring immediate attention.
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dyspnea, nasal congestion
Correct Answer: B
Rationale: A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).
The nurse is preparing to care for the client diagnosed with tuberculosis who has been coughing up blood. Which illustration best shows the PPE that the nurse should plan to wear?
- A. ppe_1.PNG
- B. ppe_2.PNG
- C. ppe_3.PNG
- D. ppe_4.PNG
Correct Answer: D
Rationale: D: N95 respirator for airborne precautions and a face shield for blood exposure are appropriate. Other options lack adequate respiratory or splash protection.