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A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct Answer: B
Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.
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A nurse enters a client's room and sees smoke coming from the trash can. What action should the nurse take first?
- A. Call for assistance
- B. Evacuate the room
- C. Attempt to put out the fire
- D. Turn off the oxygen supply
Correct Answer: B
Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.
A nurse is providing discharge instructions to a client with a prescription for home oxygen therapy. What information should the nurse include?
- A. Use synthetic fabrics to avoid static electricity
- B. Turn off the oxygen when not in use
- C. Avoid open flames or smoking near oxygen
- D. Increase the oxygen flow rate as needed
Correct Answer: C
Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fires because oxygen supports combustion. Choices A, B, and D are incorrect. Choice A is not relevant to oxygen therapy. Choice B is incorrect as oxygen should not be turned off when in use as prescribed. Choice D is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous.
A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?
- A. Apply a warm compress
- B. Discontinue the IV line
- C. Increase the IV flow rate
- D. Elevate the limb
Correct Answer: B
Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.
A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct Answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.
A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?
- A. Increased activity level
- B. Bowel inflammation
- C. Long-term use of the medication
- D. History of dehydration
Correct Answer: B
Rationale: Bowel inflammation can reduce the absorption of oral medications, leading to decreased effectiveness. In this case, the decrease in the effectiveness of the arthritis medication could be attributed to impaired absorption due to bowel inflammation. Choices A, C, and D are incorrect because increased activity level, long-term use of the medication, and history of dehydration are not directly associated with a decrease in medication effectiveness related to absorption issues.