Gold standard for nclex Exam 7 2024

T/F A client receiving TPN via a CVC is scheduled to receive an IV antibiotic. The nurse should check for compatibility, turn off the TPN for 30 min, & flush the line w/ NS. - F (TPN lines should only be used for the administration of TPN solution to prevent crystalization of the CVC tubing and disruption of the TPN infusion. Any other IV med must be administered via different IV access site) A client receiving TPN complains of N, excessive thirst, and increased frequency of voiding. The nurse should initially assess which client data? - blood glucose (Clients receiving TPN are at risk for hyperglycemia related to the high concentration of dextrose in the solution - usually composed of 10% or more dextrose in water!) lidocaine IV (a concentrated sln) must be diluted with: - D5W If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first - immerse the chest tube in a bottle of sterile water (to reestablish an underwater seal to prevent tension pneumo and mediastinal shift.) Clamping the chest tube could cause ____ - tension pneumo A client with a CVC who is receiving TPN suddenly becomes SOB; c/o CP; and is tachycardic, pale, and anxious. The nurse, suspecting an air embolism, what do you do next? - clamp the catheter (to prevent further air entry) & place the client in lateral Trendelenburg (to trap air in the RA), then notify HCP A client arrives at the ED with upper GI bleeding. What is the *priority* action? - obtain v/s (determine whether client is in hypovolemic shock from blood loss & to obtain baseline by which to monitor progress of tx) What should the RN monitor to check for the presence of carbon monoxide poisoning? What type of O2 do we administer? - Serum carboxyhemoglobin levels (most direct measure of CO poisoning); hyperbaric O2 @ 100% The nurse admits a client with MI to the CCU. What should the RN plan to do in delivering care to this client? - place client on continuous cardiac monitoring The nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. What should the RN do? - return bag to blood bank (gas bubbles could indicate possible contamination) What is the smallest gauge the nurse can administer blood through? - 20-gauge (or larger to prevent addt'l hemolysis of RBC & prevent occlusion)