Nokea
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
- A. Close the pinch clamp on the CVC.
- B. Administer oxygen via non-rebreather mask.
- C. Place the client in Trendelenburg position.
- D. Obtain emergency IV access.
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (D) is not the first priority in this situation; preventing air embolism is critical.
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A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- A. Consume a diet that is high in calories.
- B. Limit fluid intake to prevent mucus production.
- C. Engage in strenuous exercise daily.
- D. Reduce carbohydrate intake to prevent fatigue.
Correct Answer: A
Rationale: Rationale: A client with COPD often has increased energy needs due to the work of breathing. Consuming a high-calorie diet helps meet these needs. This can prevent malnutrition and promote optimal energy levels. Limiting fluid intake (B) can lead to dehydration and thicker mucus. Strenuous exercise (C) may exacerbate breathing difficulties. Reducing carbohydrate intake (D) can lead to decreased energy levels.
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the clients risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C: Oral contraceptives were taken for the last 6 years. Long-term use of oral contraceptives has been associated with a slightly increased risk of developing breast cancer. Estrogen and progesterone in oral contraceptives can stimulate the growth of breast tissue, potentially leading to cancer over time. Daily caffeine consumption (choice A) and a history of seasonal allergies (choice B) do not have a direct correlation with an increased risk of breast cancer. Routine use of multivitamins (choice D) is generally not linked to an increased risk of breast cancer.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C, D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The clients vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurses priority?
- A. Administer an antipyretic for the fever.
- B. Encourage the client to ambulate.
- C. Assess the surgical incision for signs of infection.
- D. Increase IV fluid administration.
Correct Answer: C
Rationale: The correct answer is C: Assess the surgical incision for signs of infection. This is the priority because the client has a fever (indicating possible infection) post-surgery, putting them at risk for complications. Assessing the surgical incision allows for early detection of infection, prompt treatment, and prevention of further complications. Administering an antipyretic (choice A) only addresses the symptom but not the underlying cause. Encouraging ambulation (choice B) and increasing IV fluids (choice D) are important but assessing for infection takes precedence due to the potential severity of an infected surgical site.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
- A. Surgical drain output 300 mL during an 8-hr shift
- B. Bounding peripheral pulses
- C. Neck vein distention
- D. Weight gain of 2 kg (4.4 lb) in 24 hours
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (B) and neck vein distention (C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (D) suggests fluid retention, not deficit.