A patient on the cardiac ﬂoor has just had a PlCC line placed by the MD. the Xray team has not verified the position of the catheter tip, yet. You check the heart monitor and notice she begins having an irregular heart rhythm called Atrial Fibrillation. You anticipate that the PlCC line is touching which chamber of the heart?

Left Ventricle

Right Ventricle

Right Atria

Left Atria

Answer and Explanation

The Correct Answer is C

A PICC line is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart 1. If the PICC line is touching a chamber of the heart, it is most likely touching the right atrium 2.

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Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

A. 'It is unnecessary for you to go to the restroom at this time." B. 'I can assist you to the bathroom and back to bed." C. 'I cannot assist you at this time, please wait until I finish what I’m doing”. D. 'You cannot go to the bathroom.'

Correct Answer is B

Explanation

Chest tubes are inserted to drain ﬂuid, blood, or air from the pleural space, which is the space between the lung and the chest wall. It is important to ensure that the chest tube is secured properly and the drainage system is functioning properly before the patient is ambulated. Additionally, the patient may experience discomfort or pain during ambulation, so it is important to assess and manage the patient's pain before and after ambulation.

Option A is not appropriate because it disregards the patient's need to use the restroom and may make the patient feel helpless or dependent.

Option c is not appropriate because it does not address the patient's request for assistance and may make the patient feel neglected or uncared for.

Option d is not appropriate because it is a directive statement that does not take into account the patient's autonomy or individual needs. It is important to involve the patient in the decision-making process and provide appropriate care based on their individual needs and preferences.

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Naxlex Comprehensive Predictor Exams

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Correct Answer is A

Explanation

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

Correct Answer is B

Explanation

The nurse scaring for a patient who will be needing a blood transfusion. The nurse knows that the universal recipient of blood would be considered blood type:

You are setting up a room for your patient that has a new tracheostomy. Select all of the equipment you need bring with to ensure patient is safe should the tracheostomy become dislodged:

Coughing and Deep breathing is taught to a patient to prevent recurrent pneumonia. She is educated to breathe in deeply first to over expand lung volume: this is called what?

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

The nurse provides care for the client with an asthma crisis experiencing hypoxia. Which lung sound would the nurse expect to auscultate on the physical assessment?

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?