A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received
... [Show More] for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline.
Answer, D
Rationale- Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B.
A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching?
A. Replace the stoma appliance every day.
B. Use warm tap water to irrigate the ileostomy.
C. Change the bag when the seal is broken.
D. Measure and record the ileostomy output.
Answer- C
Rationale- A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed.
An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?
A. Measure the client's calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure.
Answer- B
Rationale- All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.
The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results
Answer- C
Rationale- The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.
What is digoxin
Blood pressure medication with high toxicity
Signs of hyperkalemia
Tall/spiked T waves, prolonged QT interval, widening QRS wave
The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks.
Answer- D, attend an ostomy support group within 2 weeks
Rationale- Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B. "Do not drink or eat milk products for 1 hour prior to taking this medication."
C. "Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption."
Answer- A
Rationale- Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.
Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall?
A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts.
B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels.
C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria.
D. Serum electrolytes reveal a decreased sodium level and increased potassium level.
Answer- C
Rationale- In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult.
An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?
A. Leukocytosis and febrile
B. Polycythemia and crackles
C. Pharyngitis and sputum production
D. Confusion and tachycardia
Answer- D
Rationale- The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.
The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level.
B. While the nurse is taking the client's blood pressure, he has a carpal spasm.
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D. The client states that he will continue to drink alcohol after going home.
Answer- B
Rationale- A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A. Immediately after feeding
B. Just prior to tube feeding
C. Continuous inflation is required
D. Inflation is not required
Answer- B
Rationale- The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis. [Show Less]