A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion of Ringer's lactate at 150 mL per hr. Prior to starting the infusion, which of the following actions should the nurse take?

Apply oxygen at 3 L/min per nasal cannula.

Review the chest x-ray report.

Flush the catheter with sterile water.

Obtain a peripheral blood glucose level.

Answer and Explanation

The Correct Answer is B

A. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no

indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.

B. Review the chest x-ray report: This is the most appropriate action before initiating the IV

infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.

C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.

D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be

important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.

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Correct Answer is B

Explanation

A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.

B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.

C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."

D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.

Correct Answer is ["92"]

Explanation

Pulse pressure is the difference between systolic and diastolic blood pressure.
The client's pulse pressure is 132 - 40 = 92 mm Hg.

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Naxlex Comprehensive Predictor Exams

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Correct Answer is B

Explanation

Correct Answer is ["92"]

Explanation

A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first?

A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?

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A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hours old. The nurse should plan to notify the provider of which of the following findings?

A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

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A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?