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The healthcare professional is caring for a client with a peripheral intravenous (IV) line that has infiltrated. What is the most appropriate initial action for the healthcare professional to take?
- A. Apply a warm compress to the affected area.
- B. Discontinue the IV and restart it in another site.
- C. Aspirate the IV line and flush it with normal saline.
- D. Notify the healthcare provider immediately.
Correct Answer: B
Rationale: The correct initial action when an IV line infiltrates is to discontinue the IV and restart it in another site. This is crucial to prevent complications such as tissue damage, phlebitis, and infection that can result from the infiltration. Applying a warm compress (Choice A) is not recommended as it can exacerbate the tissue damage caused by the infiltration. Aspirating the IV line and flushing it with normal saline (Choice C) is not appropriate for an infiltrated IV line as it does not address the main issue of infiltration. While notifying the healthcare provider (Choice D) is important, the immediate priority is to discontinue the infiltrated IV to prevent further harm and ensure proper delivery of fluids or medications.
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A healthcare provider is preparing to provide hygiene care. Which principle should the provider consider when planning hygiene care?
- A. Hygiene care is not performed in the same way by all individuals.
- B. No two individuals perform hygiene in the same manner.
- C. Standardizing a patient's hygienic practices is crucial.
- D. Understanding patient needs is not essential during hygiene care.
Correct Answer: B
Rationale: The correct answer is B: 'No two individuals perform hygiene in the same manner.' It is crucial to individualize a patient's care based on understanding the patient's unique hygiene practices and preferences. Choice A is incorrect because hygiene care should be tailored to the individual's needs and preferences, not seen as routine and expected for everyone. Choice C is incorrect as standardizing a patient's hygienic practices may not address their specific needs. Choice D is incorrect because understanding patient needs is essential during hygiene care to provide personalized and effective care.
A client with a history of heart failure is admitted with weight gain and peripheral edema. Which medication should the LPN/LVN anticipate being prescribed?
- A. Lisinopril (Zestril)
- B. Furosemide (Lasix)
- C. Metoprolol (Lopressor)
- D. Simvastatin (Zocor)
Correct Answer: B
Rationale: Furosemide (Lasix) is the correct answer. In a client with heart failure experiencing weight gain and peripheral edema, the priority is to manage fluid overload. Furosemide is a loop diuretic commonly prescribed to reduce excess fluid in heart failure patients. Lisinopril (Zestril) is an ACE inhibitor used to treat hypertension and heart failure but does not directly address fluid overload. Metoprolol (Lopressor) is a beta-blocker that helps manage heart failure symptoms but does not primarily target fluid retention. Simvastatin (Zocor) is a statin used to lower cholesterol levels and is not indicated for managing fluid overload in heart failure.
Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?
- A. Assess the client's mobility
- B. Evaluate the pedal pulses
- C. Monitor skin temperature
- D. Check for swelling
Correct Answer: B
Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.
A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hours at a time
- B. Apply an ice pack to the client's back for 1 hour
- C. Remove distractions from the client's room
- D. Instruct the client to take deep, rhythmic breaths
Correct Answer: D
Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client's room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage
- B. Notify the pharmacy when wasting the medication
- C. Lock the remaining medication in the controlled substance cabinet
- D. Dispose of the vial with the remaining medication in a sharps container
Correct Answer: A
Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.