Nokea
A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?
- A. Notify the physician of readings less than 3 cm or more than 8 cm of water
- B. Use the clean technique to change the dressing at the insertion site
- C. Elevate the head of the bed to 90° to obtain CVP readings
- D. The 0 mark on the manometer should align with the client's right clavicle for the readings
Correct Answer: A
Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.
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The ED nurse is caring for a client whose native tongue is not English. The client speaks Korean and only understands a few words of English. The nurse understands that which response is best regarding how to communicate with this client?
- A. ask a bilingual family member to tell the client to point to where the pain is
- B. call the oncology unit and ask for the nurse who is a native Korean to come and translate
- C. show the client the equipment before using it, such as indicating that an IV line will be placed in the arm
- D. call for an official Korean interpreter on the facility's translator hotline to communicate with the client, family, and health care provider
Correct Answer: D
Rationale: Using an official interpreter ensures accurate, unbiased communication, adhering to ethical and legal standards for patient care.
A 19-year-old male has been experiencing vomiting and diarrhea for 3 days due to food poisoning. The nurse expects a urine specific gravity of
- A. 0.850.
- B. 1.005.
- C. 1.020.
- D. 1.041.
Correct Answer: D
Rationale: Dehydration from vomiting and diarrhea increases urine specific gravity (normal 1.005-1.030). 1.041 indicates concentrated urine due to fluid loss.
The nurse is caring for a client with advanced heart failure and cardiomyopathy. The nurse understands that involving nursing, nutritional services, cardiology, and pharmacy in the client's care team is an example of which approach?
- A. peer review
- B. team nursing
- C. multidisciplinary
- D. community nursing
Correct Answer: C
Rationale: A multidisciplinary approach integrates multiple specialties for comprehensive care, as seen with nursing, nutrition, cardiology, and pharmacy.
A client is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree AV block on the heart monitor. What medication would the nurse prepare for initial administration?
- A. Atropine
- B. Verapamil (Calan)
- C. Lidocaine (Xylocaine)
- D. Procainamide (Pronestyl)
Correct Answer: A
Rationale: Third-degree AV block with hypotension (BP 78/40) requires atropine to increase heart rate by blocking vagal activity, improving cardiac output.
Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?
- A. Fever
- B. Red urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.