An adult has a central venous line. Which of the following should the nurse include in the plan of care?

Correct Answer: D

Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues. A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care. B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications. C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D. Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.

Correct Answer: B

Rationale: Rationale: 1. Discharge planning should start at admission to ensure comprehensive preparation. 2. Early planning allows for assessment of needs and coordination of resources. 3. It promotes continuity of care and reduces risks of readmission. 4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.

Correct Answer: A

Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. "Post-trauma syndrome" encompasses the psychological and emotional distress following a traumatic event. Choice B: Psychological overreaction simplifies the client's experience and does not capture the severity or ongoing nature of the trauma symptoms. Choice C: Needs assistance coping with attack is vague and does not provide a specific diagnosis or acknowledge the clinical presentation of the client. Choice D: Mental distress related to being attacked is too broad and does not specify the specific syndrome or symptoms experienced by the client.

Correct Answer: A

Rationale: The correct answer is A: Liver. Cancer cells commonly metastasize to the liver due to its rich blood supply, making it an ideal environment for tumor growth. Liver metastasis can occur from various primary cancer sites. The liver filters blood and is susceptible to receiving cancer cells circulating in the bloodstream. Metastasis to the colon (B) is less common as it is typically the primary site for colon cancer. Metastasis to the reproductive tract (C) can occur but is not as common as liver metastasis. White blood cells (D) are a part of the immune system and do not serve as a common site for cancer metastasis.

Correct Answer: A

Rationale: Correct Answer: A (Independent intervention) Rationale: 1. Independent interventions are actions that nurses can initiate without a doctor's order. 2. Teaching a client how to administer insulin falls under the scope of nursing practice. 3. Nurses have the knowledge and authority to educate clients on self-care management. 4. This intervention does not require collaboration with other healthcare providers. Summary: B: Dependent interventions require a doctor's order. C: Interdependent interventions involve collaboration with other healthcare providers. D: Collaborative interventions involve working with other healthcare professionals.

Correct Answer: D

Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV is a known risk factor for cervical cancer as it can lead to cellular changes in the cervix. Here's the rationale: 1. HPV is a sexually transmitted infection that can cause abnormal cell growth in the cervix. 2. Persistent HPV infection is a major risk factor for developing cervical cancer. 3. Age 32 is within the typical age range for HPV infection and the development of cervical cancer. 4. Choices A, B, and C are unrelated to the primary risk factor for cervical cancer, which is HPV infection.

Correct Answer: A

Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.

Correct Answer: B

Rationale: The correct answer is B: Turn on the affected side. This position helps to promote the closure of the puncture site in the lung, reducing the risk of fluid leakage and pneumothorax. Placing the client flat in bed (A) may not allow gravity to assist in the closure of the puncture site. Turning on the unaffected side (C) may not effectively prevent fluid leakage from the puncture site. Bed rest (D) is a general instruction and does not specifically address the prevention of fluid leakage after thoracentesis.

Correct Answer: D

Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.