a nurse is caring for a client who has just had a central venous access line inserted which action should the nurse take next
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

Correct answer: B

Rationale:

2. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level. Furosemide is a potassium-wasting diuretic, and low potassium levels can lead to weakness and palpitations. Resting more often won't address the underlying issue of hypokalemia caused by furosemide. While digoxin can have side effects, it is not causing the symptoms described by the patient. Avoiding caffeine may be beneficial, but addressing the potassium level is more critical in this situation.

3. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

Correct answer: D

Rationale:

4. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

5. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

Correct answer: B

Rationale:

Similar Questions

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