Test Nurselogic Nursing Concepts Advanced LATEST UPDATE

Test: Nurselogic Nursing Concepts Advanced Question: 1 of 20 CORRECT FLAG A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a g ...

Test: Nurselogic Nursing Concepts Advanced Question: 1 of 20 CORRECT FLAG 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 FLAG 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