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What is the best way to monitor for infection in a patient with a central line?
- A. Check the central line site daily
- B. Monitor the patient's vital signs
- C. Check the central line dressing every other day
- D. Check for signs of sepsis
Correct Answer: A
Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.
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Which lab test is used to assess renal function?
- A. Check blood glucose levels
- B. Monitor serum creatinine
- C. Monitor BUN
- D. Check electrolyte levels
Correct Answer: B
Rationale: The correct answer is B: Monitor serum creatinine. Serum creatinine is a key indicator of renal function as it reflects the glomerular filtration rate. An increase in serum creatinine levels indicates impaired kidney function. Checking blood glucose levels (choice A) is not specific to assessing renal function but is used to diagnose diabetes. Monitoring BUN (choice C) is important but not as specific as serum creatinine in assessing renal function. Checking electrolyte levels (choice D) is essential in assessing kidney function but is not as specific as monitoring serum creatinine.
What is the best intervention for a patient with constipation?
- A. Administer a stool softener
- B. Encourage fluid intake
- C. Provide a high-fiber diet
- D. Administer a laxative
Correct Answer: B
Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.
A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?
- A. Avoid eating small, frequent meals.
- B. Sleep with the head of your bed elevated.
- C. Lie down after eating.
- D. Avoid drinking fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.
A nurse is caring for a client who has deep vein thrombosis. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day.
- B. Avoid massaging the affected extremity to relieve pain.
- C. Do not apply cold packs to the client's affected extremity.
- D. Elevate the client's affected extremity when in bed.
Correct Answer: D
Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.
When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?
- A. Expel any air bubbles at the top of the prefilled syringe
- B. Massage the injection site to evenly distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct Answer: C
Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.