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Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line?
- A. Use a clean technique for all dressing changes.
- B. Tape all connections of the system.
- C. Encourage bed rest.
- D. Cover the insertion site with a moisture-proof dressing.
Correct Answer: B,D
Rationale: To prevent complications with TPN via a central line, taping all connections (B) prevents dislodgement, and a moisture-proof dressing (D) reduces infection risk. Clean technique (A) is insufficient; sterile technique is required. Bed rest (C) is not necessary and may increase complications like thrombosis. CN: Pharmacological and parenteral therapies; CL: Create
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A 27-year-old female is admitted for elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact?
- A. Complaints of nausea.
- B. Repeated swallowing.
- C. Rapid respiratory rate.
- D. Feelings of anxiety.
Correct Answer: B
Rationale: Repeated swallowing may indicate postnasal bleeding, as blood may flow down the throat rather than out the nose, even if the nasal drip pad remains dry.
The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
- A. Assisting with her daily hygiene activities.
- B. Lying flat in bed.
- C. Walking in the hall.
- D. Sitting all afternoon in her room.
Correct Answer: D
Rationale: Prolonged sitting stresses the surgical site and is contraindicated post-laminectomy.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate?
- A. Maintaining an upright position.
- B. Restricting the diet to liquids until swallowing improves.
- C. Introducing foods on the unaffected side of the mouth.
- D. Keeping distractions to a minimum.
Correct Answer: B
Rationale: Restricting the diet to liquids increases aspiration risk, as liquids are harder to control. Upright positioning, using the unaffected side, and minimizing distractions reduce aspiration risk.
The nurse in the infusion center is caring for a 27-year-old male.
Item 1 of 1
• Nurses' Notes
1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
• Orders
• Infuse 1 unit of packed red blood cells
• Medical History
• Sickle cell anemia
• Depression
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
- A. pause the transfusion and discontinue the vascular access device,discontinue the packed red blood cell transfusion and return it to the blood bank
,start a new 20-gauge vascular access device in the opposite extremity,pause the transfusion obtain an order for acetaminophen - B. febrile transfusion reaction,infiltration at the vascular access device
hemolytic transfusion reaction,circulatory overload - C. discomfort and swelling at vascular access site,hemoglobin and hematocrit,temperature,blood pressure
Correct Answer:
Rationale: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling.
The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL.
It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration.
The blood pressure does not require monitoring because it does not show evidence of circulatory overload.
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” the nurse would determine that about what percentage of the client’s body surface has been burned?
- A. 18%.
- B. 27%.
- C. 45%.
- D. 64%.
Correct Answer: C
Rationale: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.