Nokea
A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Administer oxygen via non-rebreather mask
- B. Apply an occlusive dressing over the insertion site
- C. Assist the client to high Fowler position
- D. Monitor vital signs and respiratory effort
- E. Notify the health care provider
Correct Answer: A,B,D,E
Rationale: Oxygen, occlusive dressing, vital sign monitoring, and provider notification address air embolism risk and hypoxia. High Fowler may worsen air entry; semi-Fowler is preferred.
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The nurse on a pediatric unit is caring for a 2-year-old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? Select all that apply.
- A. Encourage the parent to leave the child alone for short intervals
- B. Follow the child’s home sleep schedule and routine
- C. Integrate preferred snack foods into the child’s routine
- D. Point out body changes that may occur
- E. Provide various options when choosing toys
Correct Answer: B,C,E
Rationale: Maintaining sleep routines, offering preferred snacks, and providing toy choices reduce distress by promoting familiarity and autonomy. Leaving alone or discussing body changes may increase anxiety.
A 3-year-old child had a seizure two days ago when the child's temperature was 105°F. The child has had no previous seizures. Today, the parent and the child are in the physician's office. What should the nurse include when teaching the parent?
- A. The child now has epilepsy and will need long-term care for this condition.
- B. If the child develops a fever over 101°F, administer ibuprofen.
- C. Make sure the child drinks plenty of water every day.
- D. Call the physician's office immediately if the child develops a temperature over 100.4°F.
Correct Answer: B
Rationale: A febrile seizure at 105°F in a 3-year-old without prior seizures suggests a one-time event; ibuprofen for fevers above 101°F helps prevent recurrence, while epilepsy or immediate reporting is premature.
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
- A. Repeat glycohemoglobin in 24 hours
- B. Document Accu-checks, intake and output every 4 hours
- C. Humulin N 20 units IV push
- D. IV fluids of 0.9% normal saline at 125 ml per hour
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be given by the intravenous route. Humulin N is not suitable for IV administration, making this the priority order to question.
Laboratory reference ranges
INR
0.8-1.1
The nurse receives report on 4 clients. Which of the following clients should the nurse see first?
- A. Client receiving IV vancomycin who reports discomfort at the peripheral IV site
- B. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an INR of 1.9
- C. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea
- D. Client receiving maintenance IV 0.9% sodium chloride with labeled tubing indicating that tubing was changed 48 hours ago
Correct Answer: A
Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.
The nurse is reinforcing teaching about oral hydrocortisone for a client with newly diagnosed primary adrenal insufficiency (i.e., Addison disease). Which of the following information should the nurse reinforce? Select all that apply.
- A. Discontinue hydrocortisone if you have mood changes or disruptions in behavior
- B. Report even a low-grade fever to the health care provider immediately
- C. Report signs of hyperglycemia, including increased urine, hunger, and thirst
- D. The dose of hydrocortisone may need to be increased during times of illness or injury
- E. This medication should be taken on an empty stomach to enhance absorption
Correct Answer: B,C,D
Rationale: Reporting fever, hyperglycemia, and adjusting doses during illness are critical for Addison disease management. Hydrocortisone should not be stopped abruptly, and food enhances absorption.