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. A nurse is caring for a client who has cirrhosis. Which of the following laboratory findings should the nurse expect?

A. Increased bilirubin levels
B. Decreased albumin levels
C. Increased prothrombin time
D. Decreased serum glucose levels

Correct answer: A

Rationale: Corrected Rationale: Increased bilirubin levels are expected in clients with cirrhosis due to impaired liver function. Elevated bilirubin levels are commonly seen in cirrhosis as the liver's ability to process bilirubin is compromised. Decreased albumin levels and increased prothrombin time are also associated with cirrhosis, but the most specific finding related to liver dysfunction among the choices provided is increased bilirubin levels. Decreased serum glucose levels are not typically associated with cirrhosis.

3. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

A. Glasgow Coma Scale score of 15
B. Blood drainage on the initial dressing measuring 3 cm
C. Report of dry mouth
D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

4. A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?

A. Lochia that is red and contains small clots.
B. Fundus firm at the umbilicus.
C. Fundus deviated to the right.
D. Moderate perineal pain with swelling.

Correct answer: C

Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.

5. What is the priority nursing action for a patient with respiratory distress?

A. Administer oxygen
B. Reposition the patient
C. Administer bronchodilators
D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.