Nokea
A 56-year-old woman has a subclavian triple lumen catheter that is used for administration of total parenteral nutrition (TPN). The physician has ordered that all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should
- A. clamp off the lumen and label it as 'clotted off.'
- B. gradually increase the pressure on the irrigating solution.
- C. aspirate blood from the lumen to restore patency.
- D. secure the lumen with a Luer-Lock cap and notify the physician.
Correct Answer: D
Rationale: streptokinase may used to dissolve clot, if unsuccessful, lumen is labeled as clotted off
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The neonatal nurse is instructing the family of a newborn about an apnea monitor.
The nurse should be MOST concerned if a family member makes which of the following statements?
- A. We will be able to leave our baby for brief periods of time.'
- B. We plan to sleep by our baby's crib.'
- C. We can remove the monitor during our baby's bath.'
- D. A family member will closely watch the monitor all the time.'
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates that you are looking for an incorrect statement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct-indicates a feeling that monitor may not let them know if their infant stops breathing
The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?
- A. Amount of the drainage.
- B. Character of the drainage.
- C. Consistency of the drainage.
- D. Amount of suction on the drainage system.
Correct Answer: B
Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report
While planning care for an elderly client with dementia, which of the following should be a priority for the nurse?
- A. Encourage dependency with activities of daily living.
- B. Provide flexibility in schedules due to his confusion.
- C. Limit reminiscing due to poor memory.
- D. Speak slowly in a face-to-face position.
Correct Answer: D
Rationale: is most effective when communicating with an elderly client