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A nurse is caring for a client with a central venous catheter (CVC) in place. Which action by the nurse is most effective in preventing central line-associated bloodstream infections (CLABSI)?
- A. Performing hand hygiene before and after any manipulation of the CVC.
- B. Monitoring the client's temperature every 4 hours.
- C. Administering prophylactic antibiotics.
- D. Ensuring the client maintains strict bed rest to prevent catheter movement.
Correct Answer: A
Rationale: Hand hygiene is the most effective measure to prevent CLABSI by reducing microbial contamination.
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In the early postoperative period after a bilateral adrenalectomy, the client has an increased temperature. The nurse should assess the client further for signs of:
- A. Dehydration.
- B. Poor lung expansion.
- C. Wound infection.
- D. Urinary tract infection.
Correct Answer: C
Rationale: An increased temperature post-adrenalectomy suggests wound infection, a common postoperative complication requiring prompt assessment.
A 56-year-old cancer survivor feels guilty at the 'I Can Cope' meetings. The nurse can help him manage his feelings of guilt by pointing out that:
- A. He is really angry at the terminally ill clients in the group.
- B. He is experiencing very volatile emotions.
- C. This is a spiritual response to his illness.
- D. This is a normal reaction when surviving a life-threatening experience.
Correct Answer: D
Rationale: Survivor guilt is a normal reaction for cancer survivors, especially in support groups, and acknowledging this helps the client process their emotions.
Which fluid is best for a client with renal calculi?
- A. Cranberry juice.
- B. Cola.
- C. Water.
- D. Milk.
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.
Amoxicillin trihydrate (Amoxil) 300 mg P.O. has been prescribed for a client with an oral infection. The medication is available in a liquid suspension that is available as 250 mg/5 mL. How many milliliters would the nurse administer?
Correct Answer: 6 mL
Rationale: To calculate the dose: (300 mg / 250 mg) × 5 mL = 6 mL. The nurse should administer 6 milliliters of the amoxicillin suspension to deliver the prescribed 300 mg dose.
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize