Question: 1 of 20
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Time Remaining: 16:39:47
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A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central
venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse
suspects the catheter has migrated to the jugular vein. Which of the following actions should the
nurse take first?
Obtain a chest x-ray.
The content of this question emphasizes the concept of priority setting by
determining the first action the nurse should take when suspecting a central
venous catheter has migrated to the jugular vein. Priority setting is the use
of nursing judgment when making decisions about the rank order in which to
take nursing actions. Various priority setting frameworks, such as Maslow’s
Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can
be useful in determining the priority of needed actions. Obtaining a chest x-
ray is important; however, this action should be taken after notifying the
provider when suspecting the central venous catheter has migrated to the
jugular vein. There is another option that better ensures client safety.
Notify the provider.
The content of this question emphasizes the concept of priority setting by
determining the first action the nurse should take when suspecting a central
venous catheter has migrated to the jugular vein. Priority setting is the use
of nursing judgment when making decisions about the rank order in which to
take nursing actions. Various priority setting frameworks, such as Maslow’s
Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can
be useful in determining the priority of needed actions. Notifying the provider
is important; however, this action should be taken after flushing the catheter
when suspecting a central venous catheter has migrated to the jugular vein.
There is another option that better ensures client safety.
, Stop the infusion.
MY ANSWER
The content of this question emphasizes the concept of priority setting by
determining the first action the nurse should take when suspecting a central
venous catheter has migrated to the jugular vein. Priority setting is the use
of nursing judgment when making decisions about the rank order in which to
take nursing actions. Various priority setting frameworks, such as Maslow’s
Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can
be useful in determining the priority of needed actions. Stopping the infusion
is the first action the nurse should take when suspecting a central venous
catheter has migrated to the jugular vein. This prevents further damage to
vessel and minimizes any additional harm to the client.
Flush the catheter.
The content of this question emphasizes the concept of priority setting by
determining the first action the nurse should take when suspecting a central
venous catheter has migrated to the jugular vein. Priority setting is the use
of nursing judgment when making decisions about the rank order in which to
take nursing actions. Various priority setting frameworks, such as Maslow’s
Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can
be useful in determining the priority of needed actions. Flushing the catheter
is important; however, this action should be taken after stopping the infusion
when suspecting a central venous catheter has migrated to the jugular vein.
There is another option that better ensures client safety.
Question: 2 of 20
CORRECT
Time Remaining: 16:39:09
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A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago.
Which of the following findings is associated with this diagnosis?
Elevated temperature
MY ANSWER
The content of this question emphasizes the concept of client-centered care
through identifying findings associated with a client’s diagnosis. Client-
,centered care focuses on the client and emphasizes the client’s cultural,
ethnic, and social values. The identification of expected and unexpected
findings associated with a client’s diagnosis assists the nurse to distinguish
possible unrelated complications the client might be experiencing, which
indicates the need for further investigation. The specific focus on the client
enhances the provision of safe, quality nursing care. An elevated
temperature is a finding associated with acute alcohol delirium.
Increased appetite
The content of this question emphasizes the concept of client-centered care
through identifying findings associated with a client’s diagnosis. Client-
centered care focuses on the client and emphasizes the client’s cultural,
ethnic, and social values. The identification of expected and unexpected
findings associated with a client’s diagnosis assists the nurse to distinguish
possible unrelated complications the client might be experiencing, which
indicates the need for further investigation. The specific focus on the client
enhances the provision of safe, quality nursing care. Instead of an increased
appetite, anorexia is a finding associated with acute alcohol delirium.
Drowsiness
The content of this question emphasizes the concept of client-centered care
through identifying findings associated with a client’s diagnosis. Client-
centered care focuses on the client and emphasizes the client’s cultural,
ethnic, and social values. The identification of expected and unexpected
findings associated with a client’s diagnosis assists the nurse to distinguish
possible unrelated complications the client might be experiencing, which
indicates the need for further investigation. The specific focus on the client
enhances the provision of safe, quality nursing care. Instead of drowsiness,
insomnia is a finding associated with acute alcohol delirium.
Bradycardia
The content of this question emphasizes the concept of client-centered care
through identifying findings associated with a client’s diagnosis. Client-
centered care focuses on the client and emphasizes the client’s cultural,
ethnic, and social values. The identification of expected and unexpected
findings associated with a client’s diagnosis assists the nurse to distinguish
possible unrelated complications the client might be experiencing, which
, indicates the need for further investigation. The specific focus on the client
enhances the provision of safe, quality nursing care. Instead of bradycardia,
tachycardia is a finding associated with acute alcohol delirium.
Question: 3 of 20
CORRECT
Time Remaining: 16:38:50
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A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the
following statements by the client indicates an understanding of the teaching?
“I will only be on this medication 4 to 6 months because it can lead to physical dependence.”
The content of this question emphasizes the concept of client education by
determining which statement by the client indicates effectiveness of the
teaching. Client education is the provision of health-related education to
clients to facilitate the acquisition of new knowledge and skills, adoption of
new behaviors, and modification of attitudes. It is important that evaluation
of teaching is an ongoing process instead of one that occurs only in the final
stages of the teaching process. Continual evaluation allows for adjustments
to be made as needed to enhance or improve learning. Buspirone is an
anxiolytic medication used to treat anxiety, but is different from
benzodiazepines because of the fact that it is not a CNS depressant. Because
of this, buspirone does not cause sedation, pose a risk for abuse, or interfere
with CNS depressants, such as benzodiazepines, alcohol, or barbiturates.
Buspirone can be taken for up to a year without evidence of tolerance or
physical or psychologic dependence presenting. This statement by the client
is not true and indicates that further teaching is needed.
“I will need to stop taking Xanax two weeks before I can begin taking this medication."
The content of this question emphasizes the concept of client education by
determining which statement by the client indicates effectiveness of the
teaching. Client education is the provision of health-related education to
clients to facilitate the acquisition of new knowledge and skills, adoption of
new behaviors, and modification of attitudes. It is important that evaluation
of teaching is an ongoing process instead of one that occurs only in the final