Nokea
A client has received an IV antibiotic every eight hours for four days.
- A. Which finding would cause the nurse to be concerned about postinfusion phlebitis in a client receiving IV antibiotics?
- B. Tenderness at the IV site.
- C. Increased swelling at the insertion site.
- D. Reddened area or red streaks at the site.
- E. Leaking of fluid around the IV catheter.
Correct Answer: C
Rationale: Postinfusion phlebitis is characterized by inflammation, with reddened areas or streaks along the vein. Tenderness is common, swelling suggests infiltration, and leaking indicates poor catheter placement, but redness is the hallmark of phlebitis.
You may also like to solve these questions
A client is seen in the emergency room with complaints of chest pain.
- A. Which assessment finding suggests to the nurse that the client’s chest pain is cardiac in origin?
- B. The client states that the pain is sharp and increased by deep breathing.
- C. The client reports a history of a fatty meal before the pain began.
- D. The client states that the pain is substernal and radiates to the left arm.
- E. The client reports that the pain began when he was lifting a heavy object.
Correct Answer: C
Rationale: Substernal chest pain radiating to the left arm is a classic symptom of cardiac ischemia, such as angina or myocardial infarction. Sharp pain with breathing suggests pleuritic causes, fatty meals indicate gastroinTest inal issues, and pain with lifting suggests musculoskeletal strain.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take his insulin each day at 1400 hours
- B. Engage in physical activity daily
- C. Increase the amount of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi's effect involves rebound hyperglycemia due to nighttime hypoglycemia. A bedtime snack with protein and carbohydrates prevents hypoglycemia. Options A, B, and C do not directly address this issue.
An adult is receiving lithium carbonate 600 mg tid. Which of the following observations is of greatest concern to the nurse?
- A. The serum lithium level is 1.0 mEq/L.
- B. The client states that she is going to go on a low-sodium diet.
- C. The client has gaining 10 lb in the last three months.
- D. The client says, 'I always drink a lot of water when I take the pills.'
Correct Answer: B
Rationale: A low-sodium diet increases lithium retention, risking toxicity, a serious concern requiring immediate education or intervention.
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings should the nurse report immediately?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration. Options A, B, and D are normal.