The nurse changes the subclavian dressing of a client receiving total parenteral nutrition and notes the presence of yellow drainage around the sutures anchoring the catheter. What should the nurse do first?

Obtain a culture of the drainage

Clean the insertion site and redress the area.

Check the client's temperature.

Document the findings in the chart

Answer and Explanation

The Correct Answer is C

Rationale:

A. While obtaining a culture may be indicated if infection is suspected, this is not the first action. The nurse must first assess the client for signs of systemic infection before taking any samples. Cultures will be guided by clinical findings such as fever, chills, or elevated white blood cell count.

B. Cleaning and redressing the site is part of standard care, but if the client is showing signs of infection (e.g., fever, elevated heart rate), immediate assessment of systemic involvement takes priority over routine site care.

C. The presence of yellow drainage around a central line catheter may indicate local infection, and fever could indicate systemic infection or sepsis, a life-threatening complication in clients receiving TPN. According to priority frameworks (ABCs and Maslow’s hierarchy), assessing for signs of infection or sepsis takes precedence before taking further steps like cultures or cleaning.

D. Documentation is important, but it is secondary to assessing for immediate threats to the client’s health. First, the nurse must determine whether the client is experiencing systemic infection.

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Correct Answer is ["A","B","C","E"]

Explanation

Rationale:

A. Severe pulmonary disease is a relative or absolute contraindication for liver transplantation. End-stage COPD increases perioperative risk and postoperative complications due to impaired oxygenation and poor ventilatory reserve. This finding should be reported to the provider.

B. Significant cardiovascular disease, such as severe heart failure or coronary artery disease, increases surgical risk and can be a contraindication to liver transplant. Cardiac status must be stable to tolerate surgery and immunosuppressive therapy.

C. Post-transplant patients require strict adherence to complex medication regimens, especially immunosuppressants, to prevent graft rejection. A client who cannot reliably follow instructions or manage medications is at high risk for complications, making this a contraindication.

D. Hepatitis C infection is not a contraindication to liver transplantation. In fact, liver transplants are commonly performed for end-stage liver disease secondary to hepatitis C. Antiviral therapy may be used post-transplant.

E. Active malignancy outside the liver (metastatic cancer) is an absolute contraindication because immunosuppression required after transplantation can accelerate tumor growth and metastasis, leading to poor outcomes.

A. Three-way Foley with warmed lavage fluid B. Bag-valve-mask with warmed humidified oxygen C. Cardiopulmonary bypass machine D. Several warm blankets and warming pads.

Correct Answer is D

Explanation

Rationale:

A. This method (bladder or gastric lavage with warmed fluids) is considered a core rewarming technique, but it is invasive and typically reserved for unconscious or severely unstable clients. It is not the first choice for a conscious client who can still regulate airway and tolerate noninvasive warming.

B. While warmed, humidified oxygen can help raise body temperature, the bag-valve-mask is primarily for respiratory support in clients who are not breathing adequately. A conscious client with stable breathing usually does not need this equipment.

C. This is an invasive, high-risk method used only in extreme hypothermia with cardiac instability or failure. It is not appropriate for a conscious client who can be managed with less invasive methods.

D. For a conscious client with severe hypothermia, external warming methods such as warm blankets, heating pads, or forced-air warming devices are the safest and most effective first-line interventions. They allow gradual, controlled warming while maintaining comfort and safety, and they reduce the risk of complications such as arrhythmias that can occur with rapid core warming.

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The nurse changes the subclavian dressing of a client receiving total parenteral nutrition and notes the presence of yellow drainage around the sutures anchoring the catheter. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a client who is a possible candidate for a liver transplant for contraindications of a liver transplant. Which findings should the nurse report to the provider? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

The health care provider prescribes core warming methods for a conscious client with severe hypothermia. What equipment should the nurse obtain?

Correct Answer is D

Explanation

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