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A client receiving total parenteral nutrition (TPN) through a central line suddenly develops dyspnea, chest pain, and a drop in blood pressure. What should the nurse do first?
- A. Stop the TPN infusion.
- B. Notify the healthcare provider.
- C. Place the client in Trendelenburg position.
- D. Administer oxygen at 2 liters/minute.
Correct Answer: C
Rationale: The correct answer is C: Place the client in Trendelenburg position. This is the first action to take in a client with suspected air embolism, a potential complication of central line insertion. Placing the client in Trendelenburg position with the head down and the legs elevated can help prevent air from reaching the heart and lungs. This action can help stabilize the client's condition before further interventions can be implemented.
Stopping the TPN infusion (choice A) can be important, but the priority in this situation is to address the potential air embolism. Notifying the healthcare provider (choice B) can be done after the immediate intervention. Administering oxygen (choice D) is important, but placing the client in Trendelenburg position takes precedence in this emergency situation.
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A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?
- A. Glasgow Coma Scale
- B. Assess pulses, paresthesia, and paralysis distal to the right knee
- C. Assess pulses, paresthesia, and paralysis proximal to the right knee
- D. Optic nerve using an ophthalmoscope
Correct Answer: B
Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.
A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?
- A. Apply a hypothermia unit to stabilize core temperature.
- B. Increase the client's IV fluid rate to 200 ml/hr.
- C. Call the hospital chaplain to counsel the family.
- D. Draw blood cultures x3 to detect infection.
Correct Answer: B
Rationale: The correct answer is B: Increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate hypotension, tachycardia, decreased urine output, and cool skin, suggesting hypovolemic shock. Increasing IV fluid rate will help to restore intravascular volume and improve perfusion to vital organs. This is the highest priority as it addresses the immediate physiological need for circulatory support.
Choice A is incorrect because hypothermia is not indicated based on the client's presentation. Choice C is incorrect as it does not address the client's urgent physiological needs. Choice D is incorrect as drawing blood cultures, while important, is not the most immediate priority in this situation.
A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol is a first-generation antipsychotic known to cause extrapyramidal side effects, including tardive dyskinesia, which is characterized by involuntary repetitive movements of the face and body. This side effect is a serious concern due to its potential to be irreversible. Monitoring for tardive dyskinesia is crucial in clients taking haloperidol to detect and manage symptoms promptly.
Explanation for incorrect choices:
B: Orthostatic hypotension - This side effect is more commonly associated with other antipsychotic medications, particularly second-generation ones.
C: Photosensitivity - Haloperidol does not typically cause photosensitivity as a side effect.
D: Hyperglycemia - While some antipsychotic medications may lead to metabolic side effects like hyperglycemia, haloperidol is not typically associated with this specific side effect.
The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum calcium.
- D. Serum magnesium.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Hypokalemia can exacerbate cardiac arrhythmias in patients with heart failure. Monitoring serum potassium levels is crucial to prevent complications.
Incorrect choices:
A: Serum sodium - Furosemide may cause hyponatremia, but it is less critical compared to hypokalemia in a client with heart failure.
C: Serum calcium - Furosemide does not directly affect calcium levels significantly in most cases.
D: Serum magnesium - While furosemide can cause hypomagnesemia, monitoring potassium is more essential in this scenario due to its impact on cardiac function.
A male client in the day room becomes increasingly angry and aggressive when denied a day-pass. Which action should the nurse implement?
- A. Tell him he can have a day pass if he calms down.
- B. Put the client's behavior on extinction.
- C. Decrease the volume on the television set.
- D. Instruct the client to sit down and be quiet.
Correct Answer: D
Rationale: The correct answer is D because instructing the client to sit down and be quiet is a non-confrontational and calming approach to de-escalate the situation. It helps redirect the client's focus and encourages self-regulation. Choice A may reinforce the aggressive behavior by rewarding it. Choice B (putting behavior on extinction) may escalate the situation further. Choice C (decreasing TV volume) does not address the client's behavior directly.