Nokea
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Assess the site for leakage of blood or fluids
- B. Auscultate the site for a bruit
- C. Assess the site for bruising or hematoma
- D. Inspect the site for color, warmth, and sensation
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
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- A. Magnesium sulfate
- B. Nifedipine
- C. Ritodrine
- D. Indomethacin
Correct Answer: B
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Which type of insulin can be administered by a continuous IV drip?
- A. Humulin N
- B. NPH insulin
- C. Regular insulin
- D. Lente insulin
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be administered IV.
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
- A. Humulin N
- B. Humulin R
- C. Humulin U
- D. Humulin L
Correct Answer: B
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The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
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The nurse is caring for a client with a tracheostomy. Which action is a priority during tracheostomy care?
- A. Clean the inner cannula with sterile technique.
- B. Apply a dry dressing to the tracheostomy site.
- C. Suction the tracheostomy after cleaning.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: Cleaning the inner cannula with sterile technique prevents infection and maintains airway patency, a priority. Dressings (B), suctioning (C), and tie changes (D) are secondary.