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A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe
- A. Notify the health care provider
- B. . Administer the prescribed medication.
- C. Discontinue the PICC
- D. Switch the medication to the oral route
Correct Answer: B
Rationale: The correct answer is B: Administer the prescribed medication. The nurse has assessed the client's site and reviewed the chart, indicating readiness to administer the medication. It is crucial to follow the healthcare provider's order and administer the prescribed medication as planned. Notifying the provider (A) is unnecessary if all assessments are normal. Discontinuing the PICC line (C) without a valid reason can lead to complications. Switching to oral route (D) should only be considered if there are specific contraindications for the intravenous route. It's important to prioritize safe and effective medication administration based on the client's condition and healthcare provider's orders.
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A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?
- A. You will need to wear a sling on your arm while the device is in place
- B. There is no risk of infection because sterile technique will be used during insertion.
- C. . Ask all providers to vigorously clean the connections prior to accessing the device.
- D. You will not be able to take a bath with this vascular access device.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice C is correct because it emphasizes the importance of cleaning connections before accessing the device to prevent infection.
2. Sterile technique during insertion cannot guarantee no risk of infection (Choice B).
3. Wearing a sling is unnecessary for a central vascular access device (Choice A).
4. The statement about not being able to take a bath is not accurate and is not a common restriction (Choice D).
. A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the
nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
- A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
- B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
- C. The kidneys react rapidly to compensate for imbalances in the body
- D. The kidneys regulate the bicarbonate level in the intracellular fluid.
Correct Answer: B
Rationale: Correct Answer: B - The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
Rationale:
1. In metabolic acidosis, the blood pH is low due to excess acid in the body.
2. To restore pH balance, the kidneys excrete hydrogen ions (acid) and conserve bicarbonate ions (a base).
3. By excreting acid and retaining base, the kidneys help neutralize the excess acid in the body.
4. Option B accurately describes the role of the kidneys in metabolic acidosis.
Incorrect Choices:
A: Incorrect. The kidneys do not retain hydrogen ions in metabolic acidosis; they excrete them.
C: Incorrect. While the kidneys do play a role in correcting imbalances, they do not react rapidly in metabolic acidosis.
D: Incorrect. The kidneys do regulate bicarbonate levels, but this is not the primary action in metabolic acidosis.
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications
- A. Initiate a dedicated team to insert access devices
- B. . Require additional education for all nurses.
- C. Limit the use of peripheral venous access devices.
- D. Perform quality control testing on skin preparation products.
Correct Answer: A
Rationale: The correct answer is A: Initiate a dedicated team to insert access devices. This intervention is the most effective in decreasing complications related to IV therapy because having a dedicated team specialized in inserting access devices ensures that the procedure is done correctly each time, reducing the risk of complications such as bloodstream infections.
Choice B is not as effective because additional education for all nurses may not guarantee consistent skill levels in IV insertion. Choice C may limit access but does not address the root cause of complications. Choice D focuses on skin preparation, which is important but not as impactful as having a specialized team for IV insertion.
A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?
- A. . Diabetic ketoacidosis in a person with emphysema
- B. Bronchial obstruction related to aspiration of a hot dog
- C. Anxiety-induced hyperventilation in an adolescen
- D. Diarrhea for 36 hours in an older, frail woman
Correct Answer: A
Rationale: The correct answer is A: Diabetic ketoacidosis in a person with emphysema. The arterial blood values show a low pH (acidosis), high PaCO2 (respiratory acidosis), and normal HCO3 (compensatory metabolic alkalosis). This pattern is consistent with a mixed acid-base disorder seen in diabetic ketoacidosis where metabolic acidosis from ketone production is partially compensated by respiratory acidosis from decreased alveolar ventilation due to emphysema. The other choices do not align with the given blood values. Choice B is incorrect as it would typically show respiratory alkalosis. Choice C would show respiratory alkalosis with low PaCO2. Choice D would result in metabolic acidosis with low HCO3.
After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)
- A. Strong productive cough
- B. Active bowel sounds
- C. U waves present on the electrocardiogram (ECG)
Correct Answer: C
Rationale: The correct answer is C: U waves present on the electrocardiogram (ECG). U waves are indicative of hypokalemia, and their presence indicates that the potassium chloride treatment is improving the condition.
Explanation:
1. A: Strong productive cough - This manifestation is not related to potassium levels and does not indicate improvement in hypokalemia.
2. B: Active bowel sounds - While hypokalemia can cause gastrointestinal issues, active bowel sounds alone do not specifically indicate improvement in potassium levels.
3. C: U waves present on ECG - U waves are a classic ECG finding in hypokalemia. The presence of U waves indicates a positive response to potassium chloride treatment.
4. D: No response provided - Not applicable.
In summary, the presence of U waves on the ECG is a key indicator of improvement in hypokalemia, while the other manifestations do not directly relate to potassium levels.