Nokea
The nurse is assisting the physician with removalCus of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
- A. Perform the Valsalva maneuver as the catheter is advanced
- B. Turn his head to the left side and hyperextend the neck
- C. Take slow, deep breaths as the catheter is removed
- D. Turn his head to the right while maintaining a sniffing position
Correct Answer: C
Rationale: Taking slow, deep breaths during central venous catheter removal minimizes the risk of air embolism.
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A 65-year-old client who recently retired from many years of working full-time for a company has become increasingly unmotivated and states he feels as though he has no purpose. Which of the following recommendations are most appropriate? Select all that apply.
- A. Volunteer or get a part-time job.
- B. Participate in community activities.
- C. Join a senior citizen's group.
- D. Be thankful he can afford to retire.
- E. Ask to have retirement reversed.
Correct Answer: A,B,C
Rationale: Volunteering/part-time work (A), community activities (B), and senior groups (C) provide purpose. Gratitude (D) is dismissive, and reversing retirement (E) is impractical.
The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.
The nurse is caring for a client with advanced heart failure and cardiomyopathy. The nurse understands that involving nursing, nutritional services, cardiology, and pharmacy in the client's care team is an example of which approach?
- A. peer review
- B. team nursing
- C. multidisciplinary
- D. community nursing
Correct Answer: C
Rationale: A multidisciplinary approach integrates multiple specialties for comprehensive care, as seen with nursing, nutrition, cardiology, and pharmacy.
When planning the care for a client after a posterior fossa (infratentorial) craniotomy, which action is contraindicated?
- A. Keeping the client flat on one side
- B. Elevating the head of the bed 30°
- C. Log-rolling or turning as a unit
- D. Keeping the neck in a neutral position
Correct Answer: B
Rationale: Elevating the head of the bed can increase intracranial pressure in posterior fossa craniotomy clients due to disruption of cerebrospinal fluid flow, making it contraindicated.
A client is admitted for an CAT scan. The nurse should question the client regarding:
- A. Pregnancy
- B. A titanium hip replacement
- C. Allergies to antibiotics
- D. Inability to move his feet
Correct Answer: A
Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.