Nokea
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is
- A. difference in the intake and output
- B. changes in the mucous membranes
- C. skin turgor
- D. weekly weight
Correct Answer: D
Rationale: weekly weight. The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of data collection, but they are not the most accurate indicators of fluid balance.
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The nurse completed discharge teaching for the client with sutures in place after a skin biopsy. Which statements by the client indicate an understanding of the teaching? Select all that apply.
- A. "The incision should be clean, dry, and not separated."
- B. "I will return in 2 to 3 days to have the stitches removed."
- C. "If I have an elevated temperature, I'll contact my provider."
- D. "I'll keep the bandage on for a week before I check the incision."
- E. "Excessive redness, pain, or drainage may mean it is infected."
Correct Answer: A,C,E
Rationale: A: Clean, dry, intact incisions indicate proper care. C: Fever suggests infection, requiring follow-up. E: Redness, pain, or drainage are infection signs. B: Sutures are removed in 7-10 days. D: Incisions should be checked daily.
The nurse is caring for the client with an IV. Which findings should prompt the nurse to conclude that the client is experiencing inflammation (phlebitis) at the IV insertion site? Select all that apply.
- A. Pain
- B. Redness
- C. Warmth
- D. Drainage
- E. Mottling
- F. Swelling
Correct Answer: A,B,C,F
Rationale: A: Pain indicates tissue irritation. B: Redness results from vasodilation. C: Warmth is caused by inflammation. F: Swelling occurs from fluid leakage. D: Drainage suggests infection. E: Mottling is unrelated.
The nurse is caring for hospitalized clients. Which nursing actions require the nurse to use sterile gloves? Select all that apply.
- A. Insertion of a nasogastric tube
- B. Administration of an enema
- C. Administration of a subcutaneous injection
- D. Insertion of an indwelling urinary catheter
- E. Suctioning of a tracheostomy tube
Correct Answer: D,E
Rationale: D: Sterile gloves are required for urinary catheter insertion to prevent introducing pathogens. E: Sterile gloves are needed for tracheostomy suctioning to minimize infection risk. A, B, C involve non-sterile procedures.
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: Stop the infusion. This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.
The nursing student approaches the instructor after being stuck by a bloody needle. Which instructor statement is most accurate knowing that the client was HIV-positive?
- A. "Wash with soap and water and see the HCP now; treatment should begin within 1 to 2 hours."
- B. "The first HIV antibody testing is completed in 6 weeks and then repeated in 3 months."
- C. "Wash with soap and water now. At the end of the clinical shift, notify your physician."
- D. "Flush immediately with water for 10 minutes and then cover with a bandage and glove."
Correct Answer: A
Rationale: A: Immediate washing and HCP evaluation within 1-2 hours are critical for post-exposure prophylaxis. B: Testing timing is incorrect. C: Delaying care is risky. D: Flushing is for mucosal exposure.