NCLEX RN Mastery with rationale

NCLEX RN Mastery with rationale The nurse is supervising a new nurse orientee while providing care to a client with a central venous catheter. The nurse should intervene when the new nurse is observed performing which of the following actions? A. Wearing non-sterile gloves when connecting IV tubing to the central venous catheter B. Changing the clear catheter dressing after 72 hours. C. Withdrawing venous blood directly from the catheter for a laboratory test of serum potassium. D. Flushing the unused catheter ports with a 3 mL luer lock syringe containing normal saline. - ANSWER-Flushing the unused catheter ports with a 3 mL luer lock syringe containing normal saline. RATIONALE-Only 10 mL syringes should be used to minimize pressureon the catheter. The nurse is supervising care of a graduate nurse performing gastric lavage on a client with Acetaminophen overdose. The nurse should intervene if which action is observed? A. Iced solution is instilled to promote vasoconstriction B. Changes in VS and LOC are monitored C. The client is placed in side-lying Trendelenburg D. A large bore (38 F) tube is inserted for instillation of lavage fluid - ANSWER-A. Iced solution is instilled to promote vasoconstriction RATIONALE-(A warm solutiom should be instilled to prevent irritation of the vagal nerve as well as dangerous temp changes in client) The nurse is caring for a client following a TURP procedure. Which of the following findings most concerns the nurse? A. HR of 116 bpm B. Small blood clots in the urine C. Urine output of 20 mL/hour D. Urinary retention - ANSWER-Heart rate of 116 bpm, could be a sign of infection. RATIONALE-This symptom, along with fever, should be monitored for and reported after surgery. Clients who undergo a TURP are at risk for both local and systemic complications. The nurse is caring for a client with suspected meningitis after a lumbar puncture was performed. Which of the following indicates an expected outcome after the procedure? A. The client has a small amount of bloody drainage at the insertion site. B. The client has pupils of unequal size. C. The client has a small hematoma at the insertion site. D. The client reports a HA with mild dizziness - ANSWER-The client reports a HA with mild dizziness RATIONALE-(HA is a mild but common complication that occurs in 10-30% of clients in the hours following the procedure, and maybe be accompanied by dizziness, N/V, tinnitus, and visual changes) What is a lumbar puncture procedure used to diagnose? - ANSWER-~ Serious bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis RATIONALE~ Bleeding around the brain (subarachnoid hemorrhage) ~ Certain cancers involving the brain or spinal cord ~ Certain inflammatory conditions of the nervous system, such as multiple sclerosis and Guillain-Barre syndrome Complications of lumbar puncture (spinal tap)? - ANSWER-infection, bleeding, sudural hematoma formation, and cerebral herniation The nurse is caring for a post-op client with a BUN of 60 mg/dL and a creatinine level of 3.2 mg/dL. The provider has ordered an infusion of 1 L of 0.9% NaCl with 40 mEq KCl to be administered over 2 hours. Which of the following is a priority nursing action? A. Assess the client's urinary output. B. Administer the IV fluid replacement. C. Question the infusion of 0.9% NaCl with 40 mEq KCl. D. Encourage the intake of protein rich foods in diet. - ANSWER-~ The order for 1 L of 0.9% NaCl with 40 mEq KCl should be questioned. Increased blood urea nitrogen and creatinine indicate renal dysfunction. Elevated BUN can indicate dehydration, but the creatinine also indicates renal problems. RATIONALE~ Fluids should be monitored as the