A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?

Close the pinch clamp on the CVC.

Obtain a prescription for stat ABGS (Arterial Blood Gas Studies).

Place the client in the left Trendelenburg position.

Check the tubing for placement of a locking adaptor.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.

Choice B rationale:

Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.

Choice C rationale:

Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.

Choice D rationale:

Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale:

A blood glucose level of 100 mg/dL is within the normal range, so there is no need to notify the provider of this finding.

Choice B rationale:

A client's temperature of 37.6°C (99.7°F) is slightly elevated but not considered a critical finding. It may be indicative of an infection or other mild inflammation, but it does not warrant immediate provider notification.

Choice C rationale:

A potassium level of 5.7 mEq/L is above the normal range (3.5-5.0 mEq/L). Hyperkalemia can lead to serious cardiac complications, such as arrhythmias, and requires immediate attention from the provider.

Choice D rationale:

Weight loss of 0.8 kg/day (1.8 lb/day) should be evaluated and monitored, but it is not an immediate concern that warrants urgent provider notification.

A. A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin. B. A client who has Meniere's disease and cannot safely ambulate due to vertigo. C. A client who had a stroke and cannot eat or drink without choking. D. A client whose medications to manage Parkinson's disease are no longer effective.

Correct Answer is D

Explanation

Answer: D. A client whose medications to manage Parkinson's disease are no longer effective.

Rationale:

A) A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin:

While this client has a significant medical issue, the primary concern here is financial rather than palliative. Palliative care focuses on providing relief from symptoms and improving quality of life for those with serious illnesses. Addressing the client's financial issues might involve social services or community resources rather than palliative care.

B) A client who has Meniere's disease and cannot safely ambulate due to vertigo:

Meniere's disease, while debilitating, may not necessarily require palliative care unless the symptoms are severely impacting the client's quality of life in a way that is not manageable with current treatments. Palliative care could be considered if the disease is severely limiting function and other supportive care is needed.

C) A client who had a stroke and cannot eat or drink without choking:

This client is experiencing a significant functional impairment due to the stroke, which might benefit from rehabilitative services rather than palliative care. Palliative care would be more appropriate if the client's condition is progressive, severe, and not responsive to treatment, leading to a focus on comfort and quality of life.

D) A client whose medications to manage Parkinson's disease are no longer effective:

When medications for Parkinson's disease are no longer effective, the client may be experiencing advanced symptoms and a decline in quality of life. Palliative care can provide symptom management, support, and enhance the client's quality of life when conventional treatments are no longer effective in controlling symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer total parenteral nutrition (TPN) to a client. The nurse should notify the provider of which of the following findings?

Correct Answer is C

Explanation

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

Correct Answer is D

Explanation

A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?

A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.).

A nurse is providing teaching for a client about testicular cancer. Which of the following manifestations should the nurse instruct the client to monitor for during self-examination?