the nurse is caring for a client with a central venous catheter what is the most important action for the nurse to take to prevent infection
Logo

Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.

2. During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?

Correct answer: D

Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.

3. A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

Correct answer: A

Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.

4. A healthcare professional is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?

Correct answer: A

Rationale: The correct answer is to avoid measuring the client’s temperature rectally. Rectal temperatures can cause bleeding in clients with low platelet counts. It is crucial to avoid invasive methods that could increase the risk of bleeding or discomfort. Choice B, counting the radial pulse, is not directly related to the risk of bleeding in a client with low platelet count. Choice C, counting respirations discreetly, is important for accuracy but is not the priority when considering the risk of bleeding. Choice D, letting the client rest before measuring blood pressure, is beneficial but is not the priority in preventing potential harm due to low platelet counts.

5. Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?

Correct answer: D

Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.

Similar Questions

A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?
What is the most important action for the LPN/LVN to take to prevent infection in a client with an indwelling urinary catheter?
When interviewing the parents of a child with asthma, what information about the child's environment should be gathered most importantly?
The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses