NCLEX (Top Practiced Missed Questions) 100% Verified Correct Solution 2024 A+ QUALITY
The nurse is caring for a client with a central venous
... [Show More] catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first?
1. Administer ondansetron 4 mg IV push PRN for nausea or vomiting
2. Document the occurrence and notify the hospital's epidemiology team
3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV
4. Obtain blood cultures and discontinue the central venous catheter - 1, 2. Administering medications for comfort, completion of documentation, and facility-based report protocols should be done as soon as possible. However, to prevent progression to sepsis, treatment of a suspected CRBSI should not be delayed.
3. Initiation of antibiotics is essential in treating infection and preventing its progression. However, the nurse should first draw blood cultures and remove the CVC, if possible.
4. CORRECT: When caring for a client with signs of a central line-related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection.
A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information.
1. Administer 25 units of NPH insulin now and then 12 units of regular insulin after the morning meal
2. Administer 37 units of insulin: 25 units of NPH insulin and 12 units of regular insulin in 2 separate injections
3. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the NPH into the syringe first
4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first - 1. The two insulins can be safely given together before the meal as regular insulin has a rapid onset of action, whereas NPH has a slower onset but longer duration.
2. The insulins can be given as two separate injections; however, this increases client discomfort and infection risk.
3. Regular insulin should be drawn up first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic - RN: Regular before NPH).
4. CORRECT: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic - RN: Regular before NPH).
A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?
1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest
2. Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain
3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C)
4. Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft - 1. During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90-110/min).
2. CORRECT: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.
3. Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae.
4. Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.
A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first?
1. Client who experienced a transient ischemic attack 2 days ago and is due to receive scheduled aspirin
2. Client who had a subdural hemorrhage 36 hours ago and is requesting a breakfast tray
3. Client with a bowel resection receiving total parenteral nutrition who had 4,800 mL of urine output during the last shift
4. Client with a stroke receiving tissue plasminogen activator whose Glasgow Coma Scale changed from 9 to 13 - 1. A client experiencing a transient ischemic attack has stroke-like symptoms that later resolve. Such clients are often placed on prophylactic antithrombotic treatment (eg, aspirin, clopidogrel) to prevent future strokes. This client requires scheduled medication but is not an immediate priority.
2. A client with a subdural hemorrhage should be frequently assessed for neurological changes and early symptoms of increased intracranial pressure (eg, headache, nausea). A verbal request for breakfast indicates that the client is stable and therefore does not require immediate attention.
3. CORRECT: TOTAL PARENTERAL NUTRITION (TPN) may be prescribed for clients with dysfunction of the gastrointestinal tract (eg, short bowel). GLUCOSE (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and assess for symptoms of HYPERGLYCEMIA (eg, polydipsia, POLYURIA, headaches, blurred vision). A urine output of 4,800 mL during a shift may indicate hyperglycemia. Symptomatic clients should be assessed and treated immediately as hyperglycemia can lead to SEIZURES, COMA, or DEATH.
4. Tissue plasminogen activator is administered to clients with ischemic strokes to dissolve clots in the brain. A Glasgow Coma Scale change from 9 to 13 demonstrates improving neurological status. [Show Less]