Nokea
The nurse has assisted the primary health care provider in placing a central (subclavian) catheter. Which priority action should the nurse take after the procedure?
- A. Ensure that a chest radiograph is done.
- B. Obtain a temperature reading to monitor for infection.
- C. Label the dressing with the date and time of catheter insertion.
- D. Monitor the blood pressure (BP) to check for fluid volume overload.
Correct Answer: A
Rationale: A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and verify catheter tip placement before initiating intravenous (IV) therapy. Although a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. Labeling the dressing site is important, but it is not a priority action in this situation. Although BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen flow to 4 L/min.
- B. Notify the physician immediately.
- C. Encourage the client to perform deep breathing exercises.
- D. Reposition the client to a high Fowler's position.
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should instruct the client to take the medication:
- A. With meals
- B. At bedtime
- C. Before breakfast
- D. After exercise
Correct Answer: B
Rationale: Ranitidine, an H2 receptor blocker, is most effective when taken at bedtime to reduce nighttime acid production and promote ulcer healing.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
- A. This doctor has been on our staff for 20 years.'
- B. I know you are worried, but the doctor has an excellent reputation.'
- C. You always have an option to change. Tell me about your concerns.'
- D. I take my own children to this doctor.'
Correct Answer: C
Rationale: Acknowledging the mother's concerns and offering to discuss them respects her autonomy and opens a dialogue to address specific issues, potentially resolving misunderstandings or facilitating a change if needed.
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
- A. Flexing the client's neck
- B. Leaving dentures in place
- C. Suctioning the client's mouth only if prescribed
- D. Inserting the airway with the tip pointed upward
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
- B. Torsades de Pointes
- C. Accelerated Idioventricular Arrhythmia
- D. First Degree Atrioventricular Heart Block
- E. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.