Nokea
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
- A. Allergic reaction
- B. Bowel obstruction
- C. Catheter lumen occlusion
- D. Infection
Correct Answer: D
Rationale: Abdominal pain and fever suggest peritonitis, a serious infection related to intraperitoneal therapy. Allergic reactions occur earlier, and bowel obstruction or catheter occlusion present differently.
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A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) Patient Blood coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
- A. Unique facility identifier
- B. Lot number related to the donor
- C. Name of the client receiving blood
- D. ABO group and Rh type of the donor
- E. Blood type of the client receiving blood
Correct Answer: A,B,D
Rationale: The ISBT system requires a unique facility identifier, lot number, product code, and ABO/Rh type of the donor. Client-specific information is not included on the blood label.
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication. Based on the information provided, which action should the nurse take?
- A. Notify the health care provider
- B. Administer the prescribed medication.
- C. Discontinue the PICC.
- D. Switch the medication to the oral route.
Correct Answer: B
Rationale: The PICC is intact, patent, and free from complications, indicating it is safe to administer the prescribed IV medication. No other actions are warranted based on the provided information.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
- A. Administer topical lidocaine to the site.
- B. Place warm compresses on the site.
- C. Administer prescribed oral pain medication.
- D. Massage the site with scented oils.
Correct Answer: B
Rationale: Warm compresses help relieve pain from phlebitis after catheter removal. Lidocaine, oral medication, and massage are not standard treatments for this condition.
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. Stop the infusion of intravenous fluids.
Correct Answer: D
Rationale: Edema and tenderness suggest infiltration or phlebitis, requiring immediate cessation of the infusion to prevent further tissue damage. Flushing could worsen the issue, and cold compresses or elevation are secondary actions.
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)
- A. Phlebitis
- B. Pneumothorax
- C. Thrombophlebitis
- D. Excessive bleeding
- E. Extravasion
Correct Answer: A,C
Rationale: Phlebitis and thrombophlebitis are common PICC complications. Pneumothorax is associated with subclavian catheters, not PICCs, and excessive bleeding and extravasation are less common.