how should a nurse care for a patient with a central line

ATI RN

ATI RN Exit Exam Test Bank

1. How should a healthcare professional care for a patient with a central line?

A. Flush the line daily
B. Monitor for infection
C. Change the dressing weekly
D. Replace the central line every week

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is crucial. This is because central lines can introduce bacteria into the bloodstream, leading to serious infections. While flushing the line daily and changing the dressing weekly are important aspects of central line care, monitoring for infection takes precedence. Infections can occur rapidly and have severe consequences, so early detection through vigilant monitoring is key. Replacing the central line every week is not a standard practice and should only be done when clinically indicated, such as in cases of infection or malfunction.

2. Which lab value is critical for monitoring warfarin therapy?

A. Monitor INR
B. Monitor platelet count
C. Monitor sodium levels
D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.

3. A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

A. Bowel sounds present in all four quadrants
B. Temperature of 37.5°C (99.5°F)
C. Scant urine output
D. Serosanguineous wound drainage

Correct answer: D

Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.

4. A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the intake of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.

Correct answer: D

Rationale: Administering a rectal suppository 30 minutes before scheduled defecation times is essential in a bowel-training program following a spinal cord injury. The suppository helps stimulate bowel movements and aids in establishing a regular bowel routine. Encouraging a maximum fluid intake of 1,500 ml per day (Choice A) might be beneficial for bowel function, but it is not specific to the bowel-training program. Increasing the intake of refined grains in the diet (Choice B) is not necessary and could potentially lead to constipation rather than improving bowel movements. Providing a cold drink prior to defecation (Choice C) may not directly contribute to the effectiveness of the bowel-training program compared to the use of a rectal suppository.

5. A client with lactose intolerance and has eliminated dairy products from his diet should increase consumption of which of the following foods?

A. Spinach
B. Peanut butter
C. Ground beef
D. Carrots

Correct answer: A

Rationale: Spinach is the correct answer because it is a good source of calcium. Since the client has eliminated dairy products due to lactose intolerance, which are a common source of calcium, increasing spinach consumption can help compensate for the lost calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium and therefore not the best choice for this client.