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 client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?

A. Administer nitroglycerin sublingually.
B. Administer 2L of oxygen via nasal cannula.
C. Administer aspirin 325 mg orally.
D. Obtain a 12-lead ECG.

Correct answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

3. A client in active labor requests pain management. Which of the following actions should the nurse take?

A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position.

Correct answer: B

Rationale: During active labor, nonpharmacologic comfort measures like placing the client in a warm shower are effective for pain relief. Ondansetron (Choice A) is an antiemetic and not used for pain management during labor. Applying fundal pressure (Choice C) can cause harm and is not recommended due to the risk of uterine rupture. Assisting the client to a supine position (Choice D) is not ideal in labor as it can decrease blood flow to the placenta and is associated with increased maternal complications.

4. A healthcare professional is reviewing the medical record of a client with schizophrenia. Which of the following findings should the professional report to the provider?

A. Blood pressure: 102/56 mm Hg.
B. Heart rate: 95/min.
C. Sore throat.
D. WBC count 14,000/mm^3.

Correct answer: D

Rationale: An elevated WBC count should be reported to the provider as it may indicate an infection. Elevated white blood cell counts can be a sign of an underlying infection or inflammation. Monitoring and reporting abnormal laboratory values are essential for timely interventions. The other options, such as blood pressure, heart rate, and a sore throat, while important for overall assessment, are not directly related to the potential medical urgency indicated by an elevated WBC count.

5. What is the priority nursing action for a patient with shortness of breath?

A. Administer oxygen
B. Reposition the patient
C. Check oxygen saturation
D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.