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A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the IV line
- C. Apply a cold compress
- D. Elevate the limb
Correct Answer: B
Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.
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A client with diabetes mellitus is being taught about foot care by a nurse. What statement indicates understanding?
- A. I will soak my feet in hot water every day
- B. I will wear cotton socks at all times
- C. I will cut my toenails in a rounded shape
- D. I will apply lotion between my toes after bathing
Correct Answer: B
Rationale: The correct answer is B. Wearing cotton socks is essential for clients with diabetes as it helps protect the feet and reduces the risk of skin breakdown. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage. Choice C is incorrect as clients with diabetes should cut their toenails straight across to prevent ingrown toenails. Choice D is incorrect as applying lotion between the toes can create a moist environment that may increase the risk of fungal infections.
A nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?
- A. Administer oxygen
- B. Document the seizure activity
- C. Turn the client on their side
- D. Reassure the client
Correct Answer: C
Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.
A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Orange slices
- C. Mashed potatoes
- D. Baked chicken
Correct Answer: B
Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.
A healthcare professional is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the professional use?
- A. Gait belt
- B. Mechanical lift
- C. Stand-assist lift
- D. Slide board
Correct Answer: C
Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This lift provides support and assistance for clients to stand up and be safely transferred. A gait belt is used for providing support during walking or transferring short distances for clients who need minimal assistance with balance and strength. A mechanical lift is typically used for clients who are non-weight bearing or have limited weight-bearing capacity. A slide board is utilized for transferring clients who are unable to bear weight on their legs and need assistance in sliding from one surface to another.
A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?
- A. Increase the oxygen flow rate when shortness of breath occurs
- B. Turn off the oxygen when not in use
- C. Avoid open flames or smoking near oxygen
- D. Store the oxygen tubing near heat sources
Correct Answer: C
Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.