ATI Challenge 4

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client?

"Bear down while holding breath." The client should perform a Valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new set. This action prevents air from entering the lumen, the heart, and pulmonary circulation.

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?

"I will follow a daily diet high in calories and protein." Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.

A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will turn my head in the opposite direction during insertion." The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter.

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

Assess the client's respiratory status.

A nurse is participating in a hospital committee to discuss rationing of care and resources during a pandemic. The nurse should identify that which of the following behaviors is important in providing ethical and empathetic nursing care?

Be transparent, collaborative and consistent

A nurse is preparing to insert a peripheral IV catheter. Which of the following antiseptics is the nurse's best choice for preparing the client's skin at the insertion site?

Chlorhexidine Chlorhexidine is the antiseptic preferred by the Infusion Nurses Society (INS) to decrease peripheral catheter insertion site infections.

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Clamp the catheter The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the client's respiratory status Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

Dyspnea Barrel chest Clubbing of the fingers Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

I will take my bronchodilators after meals Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

Increased anteroposterior diameter of the chest

A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

limit water intake with meals The nurse should instruct the client to limit low nutrient liquids during meals to prevent early satiety and increase intake of nutrient dense foods.