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A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
- A. Administer acetaminophen (Tylenol)
- B. Change the D5W to normal saline
- C. Discontinue the I.V.
- D. Place a warm compress on the area
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.
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The nurse is preparing to administer medication to a client. After verifying the right medication, dose, route, and time, the nurse should
- A. confirm the client's identity using two client identifiers.
- B. explain the purpose and potential side effects of the medication to the client.
- C. ensure the medication is within its expiration date.
- D. document the medication administration in the client's medical record.
Correct Answer: A
Rationale: Confirming client identity is the next step after verifying medication details to ensure safety.
The nurse identifies a medication error involving a client with a colostomy. Which action should the nurse take first?
- A. Administer the correct medication.
- B. Notify the physician and complete an incident report.
- C. Monitor the client for adverse effects.
- D. Educate the client about the error.
Correct Answer: B
Rationale: Notifying the physician and completing an incident report is the first action after a medication error to ensure proper follow-up and documentation. Administering medication, monitoring, or educating the client are secondary steps after reporting. CN: Safety and infection control; CL: Synthesize
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
- A. Put the tablet under the tongue until it is dissolved.
- B. Swallow the tablet with 120 mL of water.
- C. Chew the tablet until it is dissolved.
- D. Place the tablet between his cheek and gums.
Correct Answer: A
Rationale: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.
The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?
- A. Increase calories.
- B. Restrict sodium.
- C. Restrict potassium.
- D. Reduce fat to 10%.
Correct Answer: B
Rationale: Restricting sodium helps manage fluid retention and hypertension in Cushing's disease due to aldosterone excess.
A 92-year-old male client who is independent and lives alone has an inguinal hernia repair. Which teaching method is the best approach to use for his postoperative and discharge instructions?
- A. Written instructions with diagrams.
- B. Verbal instructions with repetition.
- C. Demonstration and return demonstration.
- D. Video instructions with follow-up.
Correct Answer: C
Rationale: Demonstration and return demonstration is the most effective for an elderly client, as it ensures understanding and ability to perform postoperative care tasks, accommodating potential sensory or cognitive limitations.