Nokea
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
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The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
- A. Oxygen saturation of 90%.
- B. Respiratory rate of 20 breaths/min.
- C. Temperature of 101°F (38.3°C).
- D. Heart rate of 80 bpm.
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime
- B. Report any chest pain
- C. Stop the medication if symptoms improve
- D. Avoid taking with calcium supplements
Correct Answer: B
Rationale: Chest pain may indicate overstimulation from levothyroxine, mimicking hyperthyroidism. Options A, C, and D are incorrect: morning dosing is preferred, stopping the medication risks relapse, and calcium supplements should be avoided but are secondary.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Avoid folic acid supplements.
- C. Report any fever or sore throat.
- D. Stop the medication if joint pain decreases.
Correct Answer: C
Rationale: Methotrexate can cause bone marrow suppression; fever or sore throat may indicate infection, requiring reporting. Options A, B, and D are incorrect.
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?
- A. Maintain a low sodium diet
- B. Take a diuretic with lithium and avoid excessive fluids
- C. Don't be overly concerned if feelings of depression occur
- D. Come in for evaluation of serum lithium levels regularly
Correct Answer: D
Rationale: Come in for evaluation of serum lithium levels regularly. Regular monitoring prevents toxicity, especially during conditions like hot weather that affect sodium levels.
The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?
- A. It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart.'
- B. It is my responsibility to witness the signature of the patient before surgery is performed.'
- C. It is my responsibility to explain the surgery and ask the patient to sign the consent form.'
- D. It is my responsibility to answer questions that the patient may have before surgery.'
Correct Answer: C
Rationale: physician should provide explanation and obtain patient's signature