which is the most important safety measure when administering a medication through a patients central venous catheter cvc
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HESI PN Exit Exam 2024 Quizlet

1. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

2. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?

Correct answer: C

Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.

3. The nurse and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to demonstrate to the UAP how to approach the client from the client's left side. Approaching the client from the neglected side (left side) can help in retraining the brain and improving awareness of the affected side, which is crucial in the management of neglect syndrome. Choice B is incorrect as assessing the client's body for bruising is not directly related to managing neglect syndrome. Choice C is incorrect as observing the interaction between the client and family members does not address the specific intervention needed for neglect syndrome. Choice D is incorrect because protecting the client's left side when transferring to a chair does not actively involve retraining the brain and improving awareness of the neglected side, which is the primary goal in managing neglect syndrome.

4. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

5. When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?

Correct answer: C

Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (Choice A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (Choice B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (Choice D) is also important but comes after ensuring safe transportation and evacuation plans are in place.

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