Nokea
The nurse is caring for a client with a peripherally inserted central catheter (PICC) in the left upper extremity. It would indicate correct nursing care if the nurse
- A. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 5 mL syringe.
- B. slowly flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.
- C. pulsatile flushes each lumen with sterile water in a 10 mL syringe.
- D. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.
Correct Answer: D
Rationale: PICC lines require pulsatile flushing with 0.9% saline in a 10 mL syringe to maintain patency and prevent occlusion.
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A nurse teaches a client experiencing heartburn to take 1 ½ oz of Maalox when symptoms appear. How many milliliters should the client take?
Correct Answer: 45 mL
Rationale: To convert ounces to milliliters: 1.5 oz × 30 mL/oz = 45 mL. The client should take 45 milliliters of Maalox.
The nurse is discussing ocular disorders with a group of nursing students. Which of the following statements would be correct for the nurse to make? Select all that apply.
- A. Cataracts are caused by increased ocular pressure (IOP).
- B. Graves' disease may cause exophthalmos.
- C. Macular degeneration is manifested by loss of peripheral vision.
- D. Angle-closure glaucoma is manifested by headache and eye pain.
- E. Hyphema results in increased aqueous humor in the anterior chamber.
Correct Answer: B,D
Rationale: Graves' disease can cause exophthalmos (bulging eyes) due to autoimmune inflammation. Angle-closure glaucoma presents with headache and eye pain due to sudden increases in intraocular pressure. Cataracts are caused by lens opacity, not IOP. Macular degeneration affects central vision, not peripheral. Hyphema is blood in the anterior chamber, not increased aqueous humor.
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.
Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:
- A. Assess the urine output
- B. Place a large bore I.V.
- C. Position onto the left side
- D. Insert a nasogastric tube
Correct Answer: B
Rationale: Severe back pain, Grey Turner's sign (flank bruising), and hemodynamic instability (hypotension, tachycardia, tachypnea) suggest a ruptured abdominal aortic aneurysm. Placing a large-bore I.V. first ensures access for fluids and blood transfusion to stabilize the client. Urine output, positioning, and nasogastric tube are secondary.
When assessing a client for early septic shock, the nurse observes for which of the following?
- A. Cool, clammy skin.
- B. Warm, flushed skin.
- C. Decreased systolic blood pressure.
- D. Hemorrhage.
Correct Answer: B
Rationale: Early septic shock is characterized by vasodilation and increased cardiac output, leading to warm, flushed skin. Cool, clammy skin and decreased blood pressure occur in later stages, and hemorrhage is not a feature of septic shock.