Nokea
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
- A. . Amount of pressure in fluid container
- B. Date of catheter tubing change
- C. Percent of heparin in infusion container
- D. . Presence of an ulnar pulse
Correct Answer: D
Rationale: The correct answer is D: Presence of an ulnar pulse. This is the most important assessment to complete first because the presence of an ulnar pulse indicates adequate circulation in the hand, ensuring that the radial artery catheter is not compromising blood flow. If the ulnar pulse is absent, it may signify impaired circulation and potential complications such as ischemia.
Choice A is incorrect because the amount of pressure in the fluid container is not directly related to the assessment of the radial artery catheter.
Choice B is incorrect because the date of catheter tubing change is important for infection control but not the immediate priority in this situation.
Choice C is incorrect as the percent of heparin in the infusion container is important for anticoagulation therapy but does not take precedence over assessing circulation in the hand.
You may also like to solve these questions
A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
- A. Potatoes and avocados can be substituted for fruit.
- B. If you cook the fruit, the amount of potassium will be lower.
- C. Berries, cherries, apples, and peaches are low in potassium.
- D. You are correct. Fruit is very high in potassium.
Correct Answer: C
Rationale: Rationale: Option C is correct because berries, cherries, apples, and peaches are indeed low in potassium compared to other fruits. This response acknowledges the client's love for fruits while providing suitable alternatives to manage potassium levels. By choosing these low-potassium fruits, the client can continue enjoying fruits without exacerbating hyperkalemia.
Incorrect options:
A: Potatoes and avocados are high in potassium, so they are not suitable substitutes.
B: Cooking fruit does not significantly reduce its potassium content.
D: This option lacks guidance and does not offer a solution to the client's concern about high potassium levels.
. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in
renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?
- A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
- B. The kidneys buffer acids through electrolyte changes
- C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
- D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
Correct Answer: C
Rationale: Rationale:
C is correct because in renal failure, the kidneys lose the ability to regenerate and reabsorb bicarbonate, which is essential for maintaining a stable pH level in the body. B is incorrect because the kidneys primarily regulate pH by controlling bicarbonate levels, not through electrolyte changes. A is incorrect because the kidneys do not regulate carbonic acid in the same way. D is incorrect as it does not accurately describe the process of pH regulation in the kidneys.
.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. . Stop the infusion of intravenous fluids.
Correct Answer: D
Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.
The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What
should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
- A. Choose a hairless site if available.
- B. Consider potential effects on the patients mobility when selecting a site.
- C. Have the patient briefly hold his arm over his head before insertion
- D. Leave the tourniquet on for at least 3 minutes.
Correct Answer: B
Rationale: The correct answer is B because considering potential effects on the patient's mobility is crucial when selecting a site for IV insertion. Mobility can be affected if the IV is placed in a joint area or on the dominant hand. This could limit the patient's ability to move freely during and after the procedure. Therefore, it is important to choose a site that will not hinder the patient's movement.
A: Choosing a hairless site is not the most important factor when selecting a site for IV insertion.
C: Having the patient hold his arm over his head before insertion is not necessary and may cause discomfort for the patient.
D: Leaving the tourniquet on for at least 3 minutes is not recommended as it can lead to complications such as venous stasis.
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
- A. Monitor daily hemoglobin and hematocrit values.
- B. Administer furosemide (Lasix) intravenously.
- C. Encourage the client to take deep breaths.
- D. Teach the client fall prevention measures.
Correct Answer: D
Rationale: The correct answer is D: Teach the client fall prevention measures. In metabolic alkalosis, the client may experience muscle weakness and confusion, increasing the risk of falls. Teaching fall prevention measures is essential to ensure the client's safety. Monitoring hemoglobin and hematocrit values (A) is not directly related to managing metabolic alkalosis. Administering furosemide (B) is not appropriate for metabolic alkalosis. Encouraging deep breaths (C) may not address the underlying cause of the alkalosis.