A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?

Verify the amount of TPN solution the client is receiving every 4 hr.

Prepare the client for a chest x-ray to verify catheter placement.

Place the client in Sims' position for catheter insertion.

Use a clean technique when changing the catheter dressing.

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Verifying the TPN solution amount is not directly related to preparing for central venous catheter insertion.
B.   Correct. Chest X-rays are typically done after central venous catheter insertion to confirm proper catheter placement.
C.   Incorrect. Sims' position is not the appropriate position for central venous catheter insertion.
The Trendelenburg position is commonly used for this purpose.
D.   Incorrect. Sterile technique, not clean technique, is used for changing the catheter dressing to prevent infection.

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Correct Answer is A

Explanation

A. Correct. Memory loss that disrupts ADLs is a characteristic feature of dementia.
B. Acute onset of confusion might be related to delirium rather than dementia.
C. Catatonia is not a typical finding in dementia.
D. Illusions are not commonly associated with dementia.

A. Oxygen saturation B. Weight C. Heart rate D. Blood pressure E. Temperature F. Sputum characteristics G. Respiratory complaint H. Travel history

Correct Answer is ["B","E","F","G","H"]

Explanation

A. The oxygen saturation is within normal range hence no need to evaluate further
B. Weight: The client has reported a significant weight loss of 2.26 kg (5 lbs.) over the past week. Unintentional weight loss can be a concerning symptom and may require further assessment.
C. Heart rate: The client's heart rate is within range.
D. Blood pressure is within normal range
E. The temperature is slightly elevated and indicates a need for further evaluation.
F. Sputum characteristics: The client reports "blood-tinged sputum." Coughing up blood in the sputum, known as hemoptysis, is a potentially serious symptom that warrants further evaluation to determine its cause.
G. Respiratory complaint: The client presents with a 4-day history of cough, often productive, along with other respiratory symptoms such as fatigue, night sweats, and a low-grade fever. These respiratory complaints require further evaluation to identify the underlying cause.
H. Travel history: The client recently traveled to South Africa and stayed for 3 weeks.
Travel history is important in assessing potential exposure to infectious diseases or other environmental factors that could contribute to the client's symptoms.

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A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record, which of the following findings indicates the need for further evaluation? Select all that apply.

Correct Answer is ["B","E","F","G","H"]

Explanation

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