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An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues.
A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care.
B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications.
C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D.
Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
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Which of the ff is an assessment finding in a client with bonchiectasis?
- A. Same amount of sputum at all stages of the disease
- B. Non productive cough
- C. Expectoration of small amounts of sputum
- D. Worsening cough with position changes
Correct Answer: D
Rationale: The correct answer is D. In bronchiectasis, worsening cough with position changes is an assessment finding due to increased sputum production and airway obstruction. This occurs because of the pooling of secretions in the affected bronchi. Choices A, B, and C are incorrect because in bronchiectasis, there is typically increased sputum production over time, productive cough with expectoration of large amounts of sputum, and cough that worsens with activity or physical exertion, rather than with position changes.
What is the last step when inserting an IV cannula?
- A. Secure the cannula with tape.
- B. Document the insertion site, date, and type of cannula used.
- C. Assess the site
- D. Place a sterile dressing over the insertion site. INFLAMMATORY AND INFECTIOUS DISTURBANCES Caring for clients with upper respiratory infections
Correct Answer: A
Rationale: The correct answer is A: Secure the cannula with tape. This is the last step in inserting an IV cannula to ensure it stays in place and prevents dislodgement or movement. Securing the cannula with tape helps maintain proper positioning and prevents accidental removal. Documenting the insertion site, date, and type of cannula used (B) is important but typically done earlier in the process. Assessing the site (C) should be done before securing the cannula to ensure proper placement. Placing a sterile dressing over the insertion site (D) is also important, but it usually comes before securing the cannula with tape to maintain a clean and sterile environment.
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client’s lifestyle, what action is most appropriate?
- A. Share these feelings with the client
- B. Discuss the negative feelings with the
- C. Develop a written interview form charge nurse
- D. Avoid eye contact with the client
Correct Answer: B
Rationale: The correct answer is B: Discuss the negative feelings with the client. This is the most appropriate action as it allows the nurse to address and manage their own biases and attitudes towards the client in a professional and constructive manner. By acknowledging and discussing these feelings with the client, the nurse can work towards providing non-judgmental care and fostering a therapeutic relationship.
A: Sharing these feelings with the client is not appropriate as it can harm the nurse-client relationship and potentially lead to discrimination.
C: Developing a written interview form is not addressing the immediate issue of the nurse's negative attitude towards the client.
D: Avoiding eye contact with the client is unprofessional and does not address the underlying issue of the nurse's negative feelings.
A client is being treated for acute pyelonephritis and will undergo laboratory tests. These tests are expected to help determine the clients BUN, creatinine, and serum electrolyte levels. Why should the nurse evaluate these test results?
- A. To determine the severity of the disorder
- B. To identify signs of fluid retention
- C. To determine the location of discomfort
- D. To determine clients response to therapy
Correct Answer: D
Rationale: The correct answer is D: To determine clients response to therapy. Evaluating BUN, creatinine, and serum electrolyte levels in a client being treated for acute pyelonephritis helps the nurse assess the effectiveness of the therapy. Changes in these levels indicate how well the kidneys are functioning and how the client is responding to treatment. Monitoring these parameters allows for adjustments in therapy if needed.
Incorrect choices:
A: To determine the severity of the disorder - While these tests can provide information about the severity of kidney dysfunction, the primary focus is on monitoring the response to therapy.
B: To identify signs of fluid retention - While BUN and creatinine levels can indirectly indicate fluid status, the main purpose of evaluating these tests is to assess therapy response.
C: To determine the location of discomfort - These tests do not provide information about the location of discomfort but rather focus on kidney function and response to treatment.
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
- A. A sudden raise in BP may occur during the first 1-3 hours after the initial dose
- B. A sudden drop in BP may occur during the first 1-3 hours after the initial dose
- C. A sudden drop in body temperature may occur during the first 1-3hours after the initial dose
- D. A sudden rise in pulse rate may occur during the first 1-3 hours after the initial dosage CARING WITH CLIENTS WITH CEREBROVASCULAR DISORDER
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications.
Incorrect choices:
A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors.
C: Angiotensin converting enzyme inhibitors do not affect body temperature.
D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate.
In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.