Nokea
A client with a central venous catheter who is receiving total parenteral nutrition (TPN) suddenly experiences signs/symptoms associated with an air embolism. The nurse should implement which interventions to minimize the client's risk for injury? Select all that apply.
- A. Monitors vital signs
- B. Clamps the catheter
- C. Checks the line for air
- D. Notifies the primary health care provider
- E. Boluses the client with 500 mL normal saline
- F. Places the client in Trendelenburg position on the left side
Correct Answer: B,D,F
Rationale: If the client experiences air embolus, the client is placed in the lateral Trendelenburg position on the left side to trap the air in the right atrium. The nurse should also clamp the catheter and notify the primary health care provider. Although vital signs are monitored continuously, doing without a related action does not directly assist the client. A fluid bolus would cause the air embolus to travel.
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The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV fistula from injury? Select all that apply.
- A. Assess pulses and circulation proximal to the fistula.
- B. Palpate for thrills and auscultate for a bruit every 4 hours.
- C. Check for bleeding and infection at hemodialysis needle insertion sites.
- D. Avoid taking blood pressure or performing venipunctures in the extremity.
- E. Instruct the client not to carry heavy objects or anything that compresses the extremity.
- F. Instruct the client not to sleep in a position that places her or his body weight on top of the extremity.
Correct Answer: B,C,D,E,F
Rationale: An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: palpate for thrills and auscultate for a bruit every 4 hours, check for bleeding and infection at hemodialysis needle insertion sites, avoid taking blood pressures or performing venipunctures in the extremity, instruct the client not to carry heavy objects or anything that compresses the extremity, instruct the client not to sleep in a position that places the body weight on top of the extremity, and the nurse should assess pulses and circulation distal to the fistula.
A primary health care provider is inserting a chest tube. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?
- A. Petrolatum jelly gauze
- B. Sterile 4 x 4 gauze pad
- C. Absorbent gauze dressing
- D. Gauze impregnated with povidone-iodine
Correct Answer: A
Rationale: The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. The items in the remaining options would not be selected as the first protective layer.
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
- A. The prescribed medication therapy has been effective.
- B. The client has been taking deep breaths as instructed.
- C. The effects of the inflammatory reaction at the site decreased.
- D. There is now an accumulation of pleural fluid in the inflamed area.
Correct Answer: D
Rationale: Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.
The nurse is reviewing the antenatal history of several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply.
- A. Of Asian heritage
- B. Two previous miscarriages
- C. Prenatal care began during the 3rd trimester
- D. History of substance abuse during pregnancy
- E. Dietary assessment identified poor eating habits
- F. Spontaneous rupture of membranes 24 hours ago
Correct Answer: C,D,E,F
Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include a history of substance abuse during pregnancy, low socioeconomic status, and poor prenatal care and nutrition. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection. There is no research to associate heritage or previous miscarriages to the development of neonatal sepsis.
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.