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 about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
- A. A client who has a history of asthma
- B. A client who has hypertension
- C. A client who has a history of migraines
- D. A client who has stable angina
Correct Answer: A
Rationale: The correct answer is A: A client who has a history of asthma. Propranolol is a non-selective beta-blocker that can potentially exacerbate bronchospasm in patients with asthma due to its mechanism of action. Therefore, the nurse should clarify the prescription with the provider before administering it to a client with asthma to avoid potential adverse effects. Choices B, C, and D are not contraindications for propranolol use, so there is no need to clarify the prescription for clients with hypertension, migraines, or stable angina.
A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?
- A. Surgical mask
- B. N95 respirator
- C. Sterile gloves
- D. Gown and face shield
Correct Answer: A
Rationale: The correct answer is A: Surgical mask. The nurse should use a surgical mask when caring for a client with bacterial meningitis to prevent the spread of infectious droplets. A surgical mask is sufficient for this infection, as it primarily spreads through respiratory droplets. Using an N95 respirator, sterile gloves, or a gown and face shield would be unnecessary and excessive for this particular situation, as they are typically reserved for airborne precautions or when there is a high risk of contact with bodily fluids. Thus, the use of a surgical mask is the most appropriate and effective choice in this scenario.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.