Nursing Elites

1. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

• A. Remove the catheter and apply direct pressure for 5 minutes.
• B. Initiate intravenous fluids as prescribed.
• C. Secure the catheter using aseptic technique.
• D. Notify the healthcare provider of the need to reposition the catheter.

Correct answer: B

Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.

2. What is the primary purpose of a chest tube in a client's care?

• A. To drain air and fluid from the pleural space
• B. To prevent infection in the thoracic cavity
• C. To assist with lung expansion
• D. To monitor intrathoracic pressure

Correct answer: A

Rationale: The correct answer is A: To drain air and fluid from the pleural space. A chest tube is primarily used to remove accumulated air or fluid in the pleural space, preventing lung collapse or compromise of lung function. This intervention aims to re-expand the lung and enhance respiratory function. Choice B is incorrect because preventing infection is not the primary purpose of a chest tube. Choice C is incorrect as lung expansion is a result of draining the pleural space, not the primary goal. Choice D is incorrect as monitoring intrathoracic pressure is not the main objective of a chest tube insertion.

3. A client with a diagnosis of hypertension is prescribed a thiazide diuretic. Which potential side effect should the nurse monitor for?

• A. Hyperkalemia
• B. Hypernatremia
• C. Hypokalemia
• D. Hypoglycemia

Correct answer: C

Rationale: The correct answer is C: 'Hypokalemia.' Thiazide diuretics commonly cause potassium loss, which can lead to hypokalemia. Monitoring potassium levels is essential when a client is taking thiazide diuretics to prevent complications such as cardiac dysrhythmias. Choices A, B, and D are incorrect. Hyperkalemia (choice A) is an elevated level of potassium, which is not typically associated with thiazide diuretics. Hypernatremia (choice B) is an elevated level of sodium, and hypoglycemia (choice D) is low blood sugar, neither of which are directly linked to thiazide diuretic use.

4. The nurse is teaching a client with diabetes about foot care. Which instruction is most important to prevent complications?

• A. Soak feet in warm water daily
• B. Apply moisturizer between the toes
• C. Wear cotton socks
• D. Inspect feet daily for cuts or sores

Correct answer: D

Rationale: The correct answer is D: Inspect feet daily for cuts or sores. Daily foot inspection is crucial for clients with diabetes to detect early signs of injury or infection. Soaking feet in warm water daily (choice A) can lead to skin maceration, making the skin more susceptible to breakdown. Applying moisturizer between the toes (choice B) can increase moisture and the risk of fungal infections. While wearing cotton socks (choice C) is beneficial for diabetic foot care, it is not as crucial as daily foot inspections to prevent complications.

5. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow the rate of transfusion.
• B. Administer an antipyretic.
• C. Stop the transfusion immediately.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

Similar Questions