how should a nurse care for a patient with a central line

ATI RN

ATI RN Exit Exam Test Bank

1. How should a healthcare professional care for a patient with a central line?

A. Flush the line daily
B. Monitor for infection
C. Change the dressing weekly
D. Replace the central line every week

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is crucial. This is because central lines can introduce bacteria into the bloodstream, leading to serious infections. While flushing the line daily and changing the dressing weekly are important aspects of central line care, monitoring for infection takes precedence. Infections can occur rapidly and have severe consequences, so early detection through vigilant monitoring is key. Replacing the central line every week is not a standard practice and should only be done when clinically indicated, such as in cases of infection or malfunction.

2. A client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

A. Heart rate of 88/min
B. Pain rating of 4 on a scale of 0 to 10
C. Respiratory rate of 10/min
D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.

3. A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?

A. Creatinine.
B. Aspartate aminotransferase (AST).
C. White blood cell count.
D. Serum glucose.

Correct answer: A

Rationale: The correct answer is A: Creatinine. Gentamicin can cause nephrotoxicity, leading to impaired kidney function. Monitoring creatinine levels helps the nurse detect any potential kidney damage. Choice B, Aspartate aminotransferase (AST), is not typically affected by gentamicin. Choice C, White blood cell count, is not directly related to gentamicin adverse effects. Choice D, Serum glucose, is not specifically monitored for gentamicin adverse effects.

4. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

A. Placing a belt restraint on a school-age child who has seizures.
B. Securing wrist restraints to the bed rails for an adolescent.
C. Applying elbow immobilizers to an infant receiving cleft lip injury.
D. Keeping the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.

5. Which lab value should be monitored in patients receiving furosemide?

A. Monitor potassium levels
B. Monitor sodium levels
C. Monitor calcium levels
D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.