Nokea
A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?
- A. Turn off the TPN for 30 minutes.
- B. Ensure a separate IV access route.
- C. Flush the CVC with normal saline.
- D. Check for compatibility with TPN.
Correct Answer: B
Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions.
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As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
- A. At the left midclavicular line at the fifth intercostal space
- B. At the left midclavicular line at the third intercostal space
- C. To the right of the left midclavicular line at the fifth intercostal space
- D. To the right of the left midclavicular line at the third intercostal space
Correct Answer: A
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.
During a follow-up visit 2 weeks after pneumonectomy, the client reports numbness and tenderness at the surgical site. Which statement should the nurse make to accurately address the client's concerns?
- A. This is not likely to be permanent, but may last for some months.
- B. You are having a severe problem and will probably be rehospitalized
- C. This is probably caused by permanent nerve damage as a result of surgery.
- D. This is often the first sign of a wound infection; I will check your temperature.
Correct Answer: A
Rationale: Clients who undergo pneumonectomy or other surgical procedures may experience numbness, altered sensation, or tenderness in the area that surrounds the incision. These sensations may last for months. It is not considered to be a severe problem and is not indicative of a wound infection.
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.
- A. Perform frequent biophysical profiles.
- B. Monitor for elevated serum creatinine.
- C. Monitor for manifestations of infection.
- D. Teach the client how to count fetal movements.
- E. Use strict sterile technique for vaginal examinations.
- F. Inform the client about the need for tocolytic therapy.
Correct Answer: A,C,D,E
Rationale: Premature rupture of membranes (PROM) increases the risk of infection, preterm labor, and fetal compromise. Frequent biophysical profiles assess fetal well-being. Monitoring for manifestations of infection is critical due to the risk of chorioamnionitis. Teaching the client to count fetal movements helps monitor fetal activity and detect potential distress. Strict sterile technique for vaginal examinations minimizes infection risk. Monitoring serum creatinine is not directly related to PROM management. Tocolytic therapy may be considered but is not universally required unless preterm labor is confirmed.
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
- A. Determine the need to increase the oxygen.
- B. Reassure the client that there is no need to worry.
- C. Conduct further assessment of the client's respiratory status.
- D. Call emergency services to take the client to the emergency department.
Correct Answer: C
Rationale: With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is 'no need to worry' is inappropriate. Calling emergency services is a premature action.