Nokea
Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?
- A. It will facilitate catheter insertion.
- B. It will make the client more comfortable during the insertion.
- C. It will prevent the occurrence of ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: The Trendelenburg position increases venous filling in the upper body, making the subclavian or jugular veins easier to access for catheter insertion.
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Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: indication that the client is approaching delirium tremens, which can be avoided with additional sedation
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
- A. Cover the defect with a moist, sterile saline gauze
- B. Place the infant in a supine position
- C. Feed the infant slowly
- D. Measure the intake and output
Correct Answer: A
Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
- A. Altered nutrition
- B. Impaired communication
- C. Risk for injury/aspiration
- D. Altered urinary elimination
Correct Answer: C
Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
- A. Immediately stop the infusion.
- B. Discontinue the PCA pump.
- C. Administer naloxone per standing orders.
- D. Administer supplementary oxygen.
- E. File an incident report.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (A), administering naloxone (C) to reverse effects, providing oxygen (D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (B) is not immediate.