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A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Verify the amount of TPN solution the client is receiving every 4 hr.
- B. Place the client in Sims' position for catheter insertion
- C. Use clean technique when changing the catheter dressing
- D. Prepare the client for a chest x-ray to verify catheter placement
Correct Answer: D
Rationale: Preparing the client for a chest x-ray to verify catheter placement is correct. A chest x-ray is required to confirm correct catheter placement before TPN administration to ensure the catheter tip is in the superior vena cava and to rule out complications like pneumothorax.
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A nurse is caring for a client who has a new diagnosis of glaucoma. Which of the following findings should the nurse expect?
- A. Blurred vision
- B. Weight loss
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Blurred vision is a common symptom of glaucoma due to increased intraocular pressure affecting the optic nerve.
A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?
- A. Instruct the parents to avoid bringing fresh flowers into the room.
- B. Use an N95 respirator.
- C. Initiate contact precautions.
- D. Place the child in a room that has a HEPA filtration system.
Correct Answer: C
Rationale: Initiating contact precautions is correct. Clostridium difficile is highly contagious and spreads through spores that can survive on surfaces. Contact precautions, including the use of gloves and gowns and proper hand hygiene with soap and water, help prevent transmission.
A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following over-the-counter medications should the nurse identify as safe for use with warfarin?
- A. Docusate
- B. Ibuprofen
- C. Aspirin
- D. Omeprazole
Correct Answer: A
Rationale: Docusate is correct. Docusate is a stool softener, and it does not have a significant effect on blood clotting. Therefore, it is considered safe for use with warfarin, which requires careful monitoring to avoid interactions that may increase bleeding risks.
A nurse is reinforcing teaching with a client who is scheduled for a cystoscopy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to fast for 12 hours before the procedure.
- B. I may have pink-tinged urine after the procedure.
- C. I will receive general anesthesia during the procedure.
- D. I should avoid urinating for 6 hours after the procedure.
Correct Answer: B
Rationale: Pink-tinged urine is expected after a cystoscopy due to minor irritation of the bladder lining.
A nurse is reinforcing teaching with a client who is scheduled for an exercise stress test. Which of the following instructions should the nurse include?
- A. Eat a large meal before the test.
- B. Wear comfortable shoes.
- C. Take a sedative before the test.
- D. Avoid drinking water during the test.
Correct Answer: B
Rationale: Wearing comfortable shoes ensures safety and ease during the physical activity required for an exercise stress test.