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An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
- A. Use sterile technique to assemble supplies needed
- B. Aspirate and discard the first 10 ml of the blood
- C. First flush the catheter with heparinized solution, then withdraw the blood
- D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C
Rationale: Before drawing blood from a central venous catheter like a Hickman type, it is essential to ensure that the catheter is patent and free of any clots. Flushing the catheter with a heparinized solution (to prevent clot formation) before withdrawing blood helps clear the catheter and ensures accurate blood sample collection. Removing clots or obstructions from the catheter is crucial to prevent complications and maintain the catheter's function. Therefore, it is important to first flush the catheter with a heparinized solution before drawing blood from it.
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Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: B
Rationale: The outcome that indicates successful fluid resuscitation in managing diarrhea is when the patient reports a decrease in stool frequency and liquidity. This is because diarrhea is characterized by an increase in stool frequency and liquidity due to the body's attempt to expel irritants or infections. By successfully resuscitating with fluids, the goal is to rehydrate the body and restore electrolyte balance, which should lead to a decrease in stool frequency and formation of more solid stools. This improvement in stool consistency and frequency is a clear indicator that the fluid resuscitation has been effective in treating the diarrhea. Therefore, option B is the correct choice for the outcome indicating successful fluid resuscitation in this scenario.
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
- A. Extremities
- B. Head
- C. Eyeball
- D. Chest and nostrils A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET L
Correct Answer: D
Rationale: The best way to assess whether a patient is breathing is to observe the movement of the chest and nostrils. Chest movement indicates inhalation and exhalation, while the nostrils may flare during breathing. Observing these two areas provides a more direct and accurate assessment of breathing compared to extremities, head, or eyeball movements. By focusing on the chest and nostrils, a nurse can quickly and effectively determine if a patient is breathing adequately.
Wilma knew that the maximum time when suctioning James is
- A. 10 seconds
- B. 20 seconds
- C. 30 seconds
- D. 45 seconds SITUATION: A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Correct Answer: C
Rationale: When suctioning a patient, it is important to limit the suctioning time to avoid hypoxia and tissue trauma. The maximum recommended time for suctioning an adult patient is usually around 10-15 seconds. However, in some cases, such as when dealing with thick or excessive secretions, the maximum time can be extended up to 30 seconds. In this particular case, where James is likely experiencing respiratory distress due to his symptoms, it would be appropriate for Wilma to suction him for a maximum of 30 seconds to effectively clear his airways while minimizing the risk of complications.
A 9mo-old infant develops a left adrenal mass; histological examination with genetic characteristics confirms neuroblastoma. Which of the following carries a better outcome?
- A. amplification of the MYCN (N-myc) proto-oncogene
- B. hyperdiploidy
- C. loss of heterozygosity of 17q chromosome
- D. loss of 1p chromosome
Correct Answer: B
Rationale: Hyperdiploidy is associated with a better prognosis in neuroblastoma.
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: For an adult receiving total parenteral nutrition (TPN), it is essential for the nurse to monitor fluid and electrolyte levels closely. TPN provides all essential nutrients, including fluids and electrolytes, directly into the bloodstream. Monitoring these levels is crucial to prevent potential complications such as fluid overload, electrolyte imbalances, and hyperglycemia. Assessing and maintaining appropriate fluid and electrolyte balance are essential components of managing a patient receiving TPN to ensure optimal patient outcomes.