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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Correct Answer is C

Explanation

Choice A rationale:
Increasing potassium consumption is unrelated to cephalexin, an antibiotic. It is not a necessary precaution or action to take while on this medication.
Choice B rationale:
Applying lotion to the skin to relieve itching is not related to cephalexin use. Itching is not a common side effect of this antibiotic, so the client's statement indicates a misunderstanding of the teaching.
Choice C rationale:
Avoiding sun exposure is essential while taking cephalexin because it is known to cause photosensitivity reactions. Sun exposure can lead to severe skin reactions, so the client's statement indicates an understanding of the teaching.
Choice D rationale:
Keeping the medication refrigerated is not necessary for cephalexin oral suspension. It should be stored at room temperature unless specified otherwise by the manufacturer. The client's statement suggests a misunderstanding of the medication storage instructions.

A. Wash in a distal to proximal direction. B. Use a circular motion with the washcloth. C. Massage legs after completing the bath. D. Disconnect the IV tubing prior to performing the bath.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.

Choice B rationale:

Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.

Choice C rationale:

Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.

Choice D rationale:

There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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 caring for a client who has chronic kidney disease. The nurse should expect the client to have which of the following clinical manifestations?

A nurse is teaching a client who has a new prescription for colesevelam powder for oral suspension. The nurse should include which of the following instructions?

A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse is reviewing the laboratory results for four clients. Which of the following results is the priority for the nurse to report to the provider?

A nurse is preparing a client for discharge who was admitted for diabetic ketoacidosis. Which of the following statements should the nurse include in the discharge teaching?

A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

A nurse is assessing a client who is receiving IV fat emulsion therapy. Which of the following findings should the nurse identify as a manifestation of fat overload syndrome?