Nokea
which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Ensure the IV tubing is primed and free of air bubbles before connecting it to the client
- C. Position the IV pump below the level of the client's heart to prevent rapid infusion
- D. Select a catheter gauge of 12 to ensure adequate fluid flow
Correct Answer: B
Rationale: The nurse should choose option B: Ensure the IV tubing is primed and free of air bubbles before connecting it to the client. This is crucial to prevent air embolism, which can be life-threatening. Priming the tubing ensures that only fluid is infused into the client's bloodstream. Air bubbles can travel to the heart and lungs, causing blockages and impairing circulation. Positioning the IV pump below the client's heart (option C) is incorrect as it can lead to rapid infusion and potential complications. Selecting a catheter gauge of 12 (option D) is not always necessary; the appropriate gauge depends on the client's condition and prescribed therapy. Obtaining a surge protector (option A) is irrelevant to the safe administration of IV therapy.
You may also like to solve these questions
Which action should the nurse take?
- A. Apply direct pressure to the wound with thick dressing material.
- B. Elevate the affected leg above heart level and apply light dressing.
- C. Apply a tourniquet immediately above the wound site.
- D. Apply ice packs to the wound to slow the bleeding.
Correct Answer: A
Rationale: The correct answer is A. Applying direct pressure to the wound with thick dressing material is the most appropriate action to control bleeding. It helps to compress the blood vessels, slowing down the bleeding. Elevating the leg (choice B) may not be enough to stop severe bleeding. Applying a tourniquet (choice C) should only be done as a last resort for life-threatening bleeding as it can lead to tissue damage. Applying ice packs (choice D) constricts blood vessels, potentially trapping harmful substances in the wound. It is crucial to address the immediate bleeding before considering other actions.
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.
- B. I will obtain the client's weight every other day.
- C. I will monitor the client's blood glucose level every eight hours.
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct answer is A because hanging a new bag of TPN and IV tubing every 24 hours helps to prevent bacterial growth and contamination, ensuring the client's safety. TPN solutions are prone to bacterial contamination if left hanging for too long, so changing the bag and tubing every 24 hours is crucial.
Summary of incorrect choices:
B: Obtaining the client's weight every other day is important for monitoring the effectiveness of TPN therapy, but it does not specifically address the procedure for administering TPN.
C: Monitoring the client's blood glucose level every eight hours is essential for managing TPN therapy, but it does not directly relate to the procedure of administering TPN.
D: Increasing the rate of TPN infusion without proper authorization or assessment can lead to serious complications such as hyperglycemia or fluid overload, making this choice incorrect.
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.
Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.