#1
Which intervention is appropriate for a patient experiencing respiratory distress?
Administering bronchodilators
ExplanationBronchodilators help dilate the airways, aiding in easier breathing during respiratory distress.
#2
What precaution should be taken when caring for a patient with a nasogastric tube?
Keeping the head of the bed elevated
ExplanationElevating the head of the bed helps prevent aspiration and facilitates proper tube functioning.
#3
In caring for a patient with a chest tube, what action requires immediate intervention?
Clamping the chest tube during transport
ExplanationClamping the chest tube can cause tension pneumothorax; hence, it needs immediate attention.
#4
Which intervention should a nurse prioritize for a patient with a central venous catheter experiencing occlusion?
Administering a thrombolytic agent
ExplanationThrombolytic agents help dissolve clots obstructing central venous catheters, restoring patency.
#5
What is a critical nursing action when caring for a patient with a urinary catheter?
Performing perineal care every shift and as needed
ExplanationPerineal care reduces the risk of infection and maintains the integrity of the perineal skin.
#6
Which intervention should the nurse prioritize for a patient at risk for venous thromboembolism?
Administering anticoagulant therapy as ordered
ExplanationAnticoagulants help prevent the formation and progression of blood clots in patients at risk for VTE.
#7
Which action is essential when caring for a patient with a wound vacuum-assisted closure (VAC) device?
Assessing for signs of infection at the wound site
ExplanationMonitoring for infection ensures timely intervention to prevent complications in wound healing.
#8
Which precaution is essential when caring for a patient with a peripherally inserted central catheter (PICC)?
Assessing for signs of phlebitis or infection regularly
ExplanationRegular assessment helps detect early signs of complications, such as phlebitis and infection.
#9
Which intervention should the nurse prioritize for a patient undergoing continuous bladder irrigation (CBI)?
Monitoring urinary output hourly
ExplanationHourly monitoring helps ensure proper CBI function and early detection of complications.
#10
Which intervention should the nurse prioritize for a patient with a chest tube experiencing excessive bubbling in the water seal chamber?
Checking for kinks or obstructions in the tubing
ExplanationIdentifying and resolving tube obstructions ensures proper drainage and prevents complications.
#11
Which precaution is essential when caring for a patient with a ventriculoperitoneal shunt?
Regularly assessing for signs of infection at the insertion site
ExplanationFrequent assessment helps detect early signs of infection, preventing serious complications.
#12
Which intervention should the nurse prioritize for a patient with an external fixator device for fracture management?
Assessing for signs of infection at the pin sites regularly
ExplanationRegular assessment helps detect early signs of pin site infection, preventing complications.
#13
Which intervention is essential when caring for a patient with an indwelling urinary catheter?
Maintaining a closed urinary drainage system
ExplanationA closed system reduces the risk of infection by preventing pathogens from entering the urinary tract.
#14
What precaution should the nurse take when caring for a patient with an endotracheal tube?
Assessing for air leakage around the tube cuff
ExplanationChecking for cuff leaks helps maintain proper ventilation and prevents aspiration.
#15
Which intervention is crucial when caring for a patient with a Jackson-Pratt drain?
Emptying the drain when it is more than half full
ExplanationRegular drainage prevents overfilling, reducing the risk of skin breakdown and infection.
#16
Which intervention is essential when caring for a patient with a Jackson-Pratt drain?
Securing the drain to the skin with a sterile dressing
ExplanationSecuring the drain prevents dislodgement and minimizes the risk of infection at the insertion site.
#17
What is a priority nursing action when caring for a patient with an arterial line?
Ensuring the transducer is at the level of the phlebostatic axis
ExplanationProper transducer placement ensures accurate pressure readings and prevents errors in monitoring.
#18
What is a primary precaution when administering intravenous potassium chloride?
Diluting the medication in a large volume of IV fluid
ExplanationDilution helps prevent irritation and damage to the veins caused by concentrated potassium chloride.
#19
Which intervention is crucial when caring for a patient with a tracheostomy tube?
Assisting with regular tracheostomy tube cuff deflation
ExplanationRegular cuff deflation prevents tracheal damage and facilitates patient comfort and weaning.
#20
What is a priority intervention for a patient receiving total parenteral nutrition (TPN)?
Monitoring blood glucose levels frequently
ExplanationFrequent monitoring helps prevent hyperglycemia and hypoglycemia, optimizing TPN therapy.
#21
What is a critical nursing action when caring for a patient with a gastrointestinal tube (e.g., Levin tube)?
Checking tube placement before each feeding or medication administration
ExplanationVerifying tube placement ensures safe and effective delivery of nutrition or medication.
#22
What is a critical nursing action when caring for a patient with a wound requiring a wet-to-dry dressing?
Irrigating the wound with sterile saline before dressing changes
ExplanationSaline irrigation helps cleanse the wound, promoting healing and preventing infection.
#23
What is a priority nursing action when caring for a patient with an implanted intrathecal pump for pain management?
Monitoring for signs of cerebrospinal fluid leakage
ExplanationDetecting CSF leakage early prevents complications such as infection or neurological damage.
#24
What is a priority nursing action when caring for a patient with a tracheostomy tube?
Suctioning the airway frequently to remove secretions
ExplanationFrequent suctioning maintains airway patency, preventing obstruction and hypoxia.
#25
Which intervention should the nurse prioritize for a patient with an arterial line?
Ensuring the transducer is level with the phlebostatic axis
ExplanationProper transducer alignment ensures accurate pressure readings, crucial for patient management.