Nokea
After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
- A. Remove the catheter and apply direct pressure for 5 minutes.
- B. Initiate intravenous fluids as prescribed.
- C. Secure the catheter using aseptic technique.
- D. Notify the healthcare provider of the need to reposition the catheter.
Correct Answer: B
Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.
You may also like to solve these questions
The nurse is caring for a client who is NPO (nothing by mouth) due to a small bowel obstruction. Which nursing intervention is most important?
- A. Monitor bowel sounds
- B. Provide frequent oral care
- C. Encourage ambulation
- D. Measure abdominal girth
Correct Answer: B
Rationale: Providing frequent oral care is crucial when a client is NPO to ensure comfort and prevent drying of the oral mucosa. In this situation, the priority is maintaining oral hygiene to prevent complications such as oral mucosa breakdown. Monitoring bowel sounds may be important in assessing bowel activity, but it is not the priority when the client is NPO due to a small bowel obstruction. Encouraging ambulation can be beneficial for other conditions, but in this case, oral care takes precedence. Measuring abdominal girth is more relevant for assessing abdominal distention, which is not the priority when the client is NPO. Therefore, the most important nursing intervention is to provide frequent oral care.
A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly
- B. Provide a complex carbohydrate snack
- C. Administer 50% dextrose intravenously
- D. Give 15 grams of a fast-acting carbohydrate
Correct Answer: D
Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.
Which client is at the highest risk for developing pressure ulcers?
- A. A 50-year-old client with a fractured femur
- B. A 30-year-old client with diabetes mellitus
- C. A 65-year-old client with limited mobility
- D. A 70-year-old client with a history of stroke
Correct Answer: C
Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.
Which membrane lines the abdominal cavity?
- A. Perineum
- B. Pericardium
- C. Pleura
- D. Peritoneum
Correct Answer: D
Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.
A client with a diagnosis of myocardial infarction (MI) is prescribed nitroglycerin. What is the primary action of this medication?
- A. Increases heart rate
- B. Lowers blood pressure
- C. Dilates coronary arteries
- D. Reduces myocardial oxygen demand
Correct Answer: C
Rationale: The correct answer is C: Nitroglycerin dilates coronary arteries, improving blood flow to the heart muscle. This helps increase oxygen supply to the heart tissue. Option A, 'Increases heart rate,' is incorrect because nitroglycerin does not directly affect heart rate. Option B, 'Lowers blood pressure,' is also incorrect as while nitroglycerin can lower blood pressure, its primary action in the context of MI is related to coronary artery dilation. Option D, 'Reduces myocardial oxygen demand,' is not the primary action of nitroglycerin in the treatment of myocardial infarction; its main action is to increase oxygen supply by dilating coronary arteries.