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A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
- A. Administer a sublingual nitroglycerin tablet
- B. Prepare to assist with chest tube insertion.
- C. . Place a sterile dressing over the IV site
- D. Re-position the client into the Trendelenburg position.
Correct Answer: B
Rationale: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a potential complication. Chest tube insertion is indicated to help re-expand the lung and relieve the pressure in the thoracic cavity. This intervention takes priority over the other options because it addresses the potential life-threatening complication of a pneumothorax. Administering nitroglycerin (choice A) is not indicated for chest pain in this scenario. Placing a sterile dressing over the IV site (choice C) is not appropriate for managing chest pain and difficulty breathing. Re-positioning the client into the Trendelenburg position (choice D) is not effective in addressing a pneumothorax and may worsen the client's condition.
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A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?
- A. Furosemide (Lasix) 40 mg intravenous push
- B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
- C. Mechanical ventilation
- D. Indwelling urinary catheter
Correct Answer: B
Rationale: The correct answer is B: Sodium bicarbonate 100 mEq diluted in 1 L of D5W. In this case, the client is experiencing metabolic acidosis due to low HCO3 levels (16 mEq/L) with a low pH (7.28). Sodium bicarbonate helps correct metabolic acidosis by increasing the HCO3 levels. Furosemide (A) is a diuretic and can worsen the client's electrolyte imbalance. Mechanical ventilation (C) is not indicated for metabolic acidosis. Indwelling urinary catheter (D) does not address the underlying acid-base imbalance. Therefore, the nurse should expect the provider to order sodium bicarbonate to correct the metabolic acidosis.
While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?
- A. Client with pancreatitis who has continuous nasogastric suctioning
- B. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
- C. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
- D. Client with uncontrolled diabetes and a serum pH level of 7.33
Correct Answer: A
Rationale: The correct answer is A: Client with pancreatitis who has continuous nasogastric suctioning. Pancreatitis can lead to gastrointestinal losses of potassium, and continuous nasogastric suctioning can further exacerbate this potassium loss, putting the client at risk for hypokalemia. The other choices are incorrect because:
B: ACE inhibitors can cause hyperkalemia, not hypokalemia.
C: Blood transfusions can lead to hyperkalemia due to the potassium content in blood products.
D: Uncontrolled diabetes and a serum pH level of 7.33 are not directly associated with hypokalemia.
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
- A. . Cardiac rate and rhythm
- B. Skin and mucous membranes
- C. Musculoskeletal strength
- D. Level of orientation
Correct Answer: A
Rationale: The correct answer is A: Cardiac rate and rhythm. In an acid-base imbalance, the pH is below the normal range indicating acidosis. The nurse should assess the cardiac rate and rhythm first because acidosis can have negative effects on the cardiovascular system. Acidosis can lead to arrhythmias and decreased cardiac output. Monitoring the cardiac rate and rhythm is crucial to detect any cardiac complications early. Choices B, C, and D are not the priority in this situation as they are not directly impacted by acid-base imbalances.
The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the
circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities.
Sympathetic stimulation constricts renal arterioles, causing what effect?
- A. Decrease in the release of aldosterone
- B. Increase of filtration in the Loop of Henle
- C. Decrease in the reabsorption of sodium
- D. Decrease in glomerular filtration
Correct Answer: D
Rationale: The correct answer is D: Decrease in glomerular filtration. Sympathetic stimulation constricts renal arterioles, leading to decreased blood flow to the kidneys. This reduction in blood flow decreases the glomerular filtration rate, impacting the kidney's ability to filter blood and produce urine. The constriction of renal arterioles does not directly affect the release of aldosterone (choice A), filtration in the Loop of Henle (choice B), or the reabsorption of sodium (choice C). The primary effect of sympathetic stimulation on renal arterioles is to decrease glomerular filtration by reducing blood flow to the kidneys.
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe
- A. Notify the health care provider
- B. . Administer the prescribed medication.
- C. Discontinue the PICC
- D. Switch the medication to the oral route
Correct Answer: B
Rationale: The correct answer is B: Administer the prescribed medication. The nurse has assessed the client's site and reviewed the chart, indicating readiness to administer the medication. It is crucial to follow the healthcare provider's order and administer the prescribed medication as planned. Notifying the provider (A) is unnecessary if all assessments are normal. Discontinuing the PICC line (C) without a valid reason can lead to complications. Switching to oral route (D) should only be considered if there are specific contraindications for the intravenous route. It's important to prioritize safe and effective medication administration based on the client's condition and healthcare provider's orders.