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 B

Explanation

Fluid retention is a common complication in heart failure, and monitoring the client's ﬂuid status is crucial to manage the condition eﬀectively. Daily weights are an essential component of monitoring ﬂuid status and are the most sensitive and practical method to detect changes in the client's ﬂuid status. Weight gain is a reliable indicator of ﬂuid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.

Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's ﬂuid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in ﬂuid balance, but it does not provide a direct indication of ﬂuid status. Output measurements can indicate ﬂuid loss, but they do not provide an accurate assessment of ﬂuid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to ﬂuid status.

A. Stop the transfusion. B. Notify the health care provider of the client s response. C. Check the client s vital signs. D. Document the findings.

Correct Answer is A

Explanation

Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.

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Naxlex Comprehensive Predictor Exams

A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

Correct Answer is B

Explanation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Correct Answer is A

Explanation

Your patient has a CMP drawn to determine their electrolytes. Only part of the values have resulted including the Na+ which is 121 mEq/l. What type of electrolyte imbalance is the patient having?

A patient newly diagnosed with heart failure understands that heart failure means there is a lack of sufficient blood supply to the patient's tissue throughout the body tells you that the is responsible for pumping blood from the hear t to the lest of the body.

The nurse is working in the intensive care unit and has just received lab results for her patients. Which of the following are considered electrolyte imbalances? (Select all That Apply)

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

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?

The nurse is discussing car safety with the mother of a 6-year-old child. The child’s mother questions the need for the use of special car seats for her child. What information can be provided to her?

During a Cardiac Stress test, a patient complains of chest pain while running The chest pain subsides when he stops running and is relaxed. The patient is diagnosed with Stable angina and is given education by the nurse. He understands the lack of muscles is causing stable angina during exercise.

The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?