Nokea
While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?
- A. Remove the cap and apply direct gentle pressure with the syringe
- B. Contact the healthcare provider regarding the need for a chest x-ray
- C. Cover the cap with tape and label the port as being obstructed
- D. Remove the catheter while applying gentle pressure at the insertion site
Correct Answer: B
Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.
You may also like to solve these questions
The charge nurse of a cardiac telemetry unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client should be assigned to the RN?
- A. One day after a permanent pacemaker insertion, a client's telemetry monitor shows a pacer rhythm.
- B. Two hours after undergoing cardioversion, a client's telemetry monitor shows a normal sinus rhythm.
- C. A client started on carvedilol the previous day for heart failure has controlled atrial fibrillation.
- D. Four hours after admission, a client with syncope shows complete heart block on the telemetry monitor.
Correct Answer: D
Rationale: The correct answer is D because complete heart block is a critical condition that requires immediate assessment and management by a registered nurse (RN). In complete heart block, there is a significant conduction disturbance that can lead to serious complications. The RN is better equipped to handle such complex and potentially life-threatening situations. Choices A, B, and C involve less critical conditions that can be managed by a practical nurse (PN) under the supervision of the RN. Therefore, assigning the client with complete heart block to the RN ensures prompt and appropriate intervention.
A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, "I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home". What response is best for the nurse to provide?
- A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
- B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
- C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
- D. Why are you so anxious to leave the hospital when you know you are not well enough yet?
Correct Answer: A
Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.
An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?
- A. Invite him to participate in the evening group activity
- B. Schedule frequent private phone calls to his parents
- C. Provide access to a variety of video games in his room
- D. Encourage him to learn his way around the hospital
Correct Answer: A
Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment.
Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.
A female client is admitted for a diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?
- A. Understands the importance of timing insulin administration 30 minutes before eating
- B. Frequently includes fruits and vegetables in meals and snacks
- C. Has access to someone who can assist with meal preparation and monitoring
- D. Demonstrates willingness to consistently follow the prescribed diet
Correct Answer: D
Rationale: The most crucial characteristic for successful adherence to a diabetic diet is the client's willingness to consistently follow the prescribed diet plan. Option A, understanding insulin timing, is important for treatment but not directly related to dietary adherence. Option B, consuming fruits and vegetables, is a healthy practice but does not ensure adherence to a specific diabetic diet. Option C, having assistance with meal preparation, is beneficial but not as essential as the client's personal commitment to adhering to the diet consistently.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Describes a schedule for antacid use in combination with other prescribed medications
- B. Selects a pattern of small meals interspersed with fluid intake
- C. Commits to engaging in a variety of stress reduction techniques
- D. Expresses a commitment to decrease nicotine intake
Correct Answer: B
Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.