The nurse is working on a cardiac unit with several patients who have intravenous access lines. The nurse identifies the following are considered central venous catheters: (Select All That Apply)

Midline catheter

Tunneled catheter

Non-Tunneled catheter

Peripheral IV

PlCC Line

Answer and Explanation

Correct Answer : B,C,E

Explanation: Central venous catheters are catheters that are inserted through a vein in the chest, neck, or groin and then threaded through to a large vein near the heart. These types of catheters are used for long- term treatment and monitoring of critically ill patients.

A midline catheter is a type of peripheral IV catheter that is longer and extends into the upper arm, but it does not reach a central vein and is not considered a central line. Therefore, option a. is incorrect.

A peripheral IV catheter is inserted into a peripheral vein (e.g., hand, arm), and it does not reach a central vein, making it a peripheral line. Therefore, option d. is incorrect.

A tunneled catheter is a type of central venous catheter that is inserted through a small incision in the chest and then tunneled under the skin to a central vein. It is typically used for long-term treatment and is less likely to become infected than a non-tunneled catheter. Therefore, option b. is correct.

A non-tunneled catheter is a type of central venous catheter that is inserted directly into a central vein in the chest, neck, or groin. It is typically used for short-term treatment and is more likely to become infected than a tunneled catheter. Therefore, option c. is correct.

A PICC line (peripherally inserted central catheter) is a type of central venous catheter that is inserted through a vein in the arm and then threaded through to a central vein near the heart. It is typically used for long-term treatment and is less invasive than other types of central lines. Therefore, option e. is correct.

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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. Rales B. Crackles C. Rhonchi D. Stridor

Correct Answer is B

Explanation

Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with ﬂuid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.

Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.

Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.

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The nurse is working on a cardiac unit with several patients who have intravenous access lines. The nurse identifies the following are considered central venous catheters: (Select All That Apply)

Nursing Test Bank

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 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?

Correct Answer is B

Explanation

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