#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 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.
#9
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.
#10
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.
#11
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.
#12
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.
#13
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.