Exam 1 455
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? A. "I will have to stay in bed for several hours after the procedure." B. "I will turn my head in the opposite direction during insertion." C. "I will need to hold my breath when they first put the needle in." D. "I will call the clinic if I have persistent hiccups."
A. "I will have to stay in bed for several hours after the procedure." B. "I will turn my head in the opposite direction during insertion." Feedback: The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter. C. "I will need to hold my breath when they first put the needle in." D. "I will call the clinic if I have persistent hiccups."
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? A. "Sit in semi-Fowler's position." B. "Bear down while holding breath." C. "Exhale slowly." D. "Turn head to the right."
A. "Sit in semi-Fowler's position." B. "Bear down while holding breath." Feedback: 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. C. "Exhale slowly." D. "Turn head to the right."
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Raise the foot of the bed to a 90° angle.
A. Administer oxygen via nasal cannula. Feedback: The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Raise the foot of the bed to a 90° angle.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? A. Apply a cold pack to the client's upper arm. B. Notify the provider who inserted the PICC line. C. Measure the circumference of both upper arms. D. Remove the PICC line.
A. Apply a cold pack to the client's upper arm. B. Notify the provider who inserted the PICC line. C. Measure the circumference of both upper arms. Feedback: The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture. D. Remove the PICC line.
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? A. Clamp the catheter. B. Initiate oxygen therapy. C. Auscultate breath sounds. D. Position the client in left lateral Trendelenburg.
A. Clamp the catheter. Feedback: 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. B. Initiate oxygen therapy. C. Auscultate breath sounds. D. Position the client in left lateral Trendelenburg.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Febrile B. Acute pain C. Hemolytic Feedback: A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse. D. Allergic
A. Febrile B. Acute pain C. Hemolytic Feedback: A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse. D. Allergic
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.
A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. Feedback: To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning. D. Limit each suction pass to 25 seconds.
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? A. Remove the catheter. B. Place the client on his left side in Trendelenburg position. C. Prepare for chest tube insertion. D. Replace the infusion system.
A. Remove the catheter. B. Place the client on his left side in Trendelenburg position. Feedback: This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system. Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system. C. Prepare for chest tube insertion. D. Replace the infusion system.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Suction the client less frequently. B. Perform pre-oxygenation prior to suctioning. C. Obtain a cardiology consult. D. Administer an antidysrhythmic medication.
A. Suction the client less frequently. B. Perform pre-oxygenation prior to suctioning. Feedback: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen. C. Obtain a cardiology consult. D. Administer an antidysrhythmic medication.
A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? A. Use a 10-mL syringe to flush the catheter. B. Flush the lumen with sterile water after each use. C. Use clean technique when accessing the catheter. D. Apply firm pressure to the syringe plunger when flushing the lumen.
A. Use a 10-mL syringe to flush the catheter. Feedback: During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter. B. Flush the lumen with sterile water after each use. C. Use clean technique when accessing the catheter. D. Apply firm pressure to the syringe plunger when flushing the lumen.
