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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.
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A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial
blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg.
What does the ABG reflect?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. A low pH (7.21) indicates acidosis. The elevated PaCO2 (64 mm Hg) indicates respiratory acidosis, as high CO2 levels lead to carbonic acid formation, decreasing pH. The normal HCO3 (24 mm Hg) suggests compensation for the respiratory acidosis. Other choices are incorrect as they do not align with the ABG values provided. Metabolic alkalosis (B) would have a high pH and HCO3, respiratory alkalosis (C) would have a high pH and low PaCO2, and metabolic acidosis (D) would have a low pH and HCO3.
The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a
positive Chvosteks sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia.
Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign.
Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm.
Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability.
Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
- A. The initial site dressing is 3 days old.
- B. The PICC was inserted 4 weeks ago.
- C. A securement device is absent.
- D. Upper extremity swelling is noted.
Correct Answer: D
Rationale: The correct answer is D because upper extremity swelling could indicate a potential complication such as deep vein thrombosis, which is a serious condition requiring immediate attention to prevent further complications. Swelling can impede blood flow and lead to clot formation.
A: The initial site dressing being 3 days old is concerning for infection but not an immediate threat.
B: The PICC being inserted 4 weeks ago may increase infection risk but does not require immediate attention.
C: A missing securement device may increase the risk of dislodgement but is not an immediate threat compared to potential vascular compromise indicated by upper extremity swelling.
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.
You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be
most consistent with this diagnosis?
- A. Hypertension
- B. Kussmaul respirations
- C. Increased DTRs
- D. Shallow respirations
Correct Answer: D
Rationale: The correct answer is D: Shallow respirations. Hypermagnesemia can lead to respiratory depression due to its inhibitory effect on the central nervous system. Shallow respirations are a common respiratory manifestation of hypermagnesemia. Hypertension (choice A) is not typically associated with hypermagnesemia. Kussmaul respirations (choice B) are deep, rapid breathing patterns seen in metabolic acidosis, not hypermagnesemia. Increased deep tendon reflexes (DTRs) (choice C) are more indicative of hypomagnesemia, as magnesium deficiency can lead to hyperexcitability of nerves and muscles, resulting in increased DTRs.