a nurse is caring for a client who is having a subclavian central venous catheter inserted the client begins to report chest pain and difficulty breat
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

Correct answer: B

Rationale:

2. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

Correct answer: B

Rationale:

3. The nurse assessing skin turgor in an elderly patient should remember that:

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

4. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

Correct answer: B

Rationale:

5. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?

Correct answer: C

Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.

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