Nokea
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. Continue the infusion
- B. Increase the infusion rate
- C. Discontinue the infusion
- D. Apply a cold compress
Correct Answer: C
Rationale: The symptoms suggest phlebitis. The nurse should discontinue the infusion and may apply a warm compress.
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A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
- A. Assault
- B. Battery
- C. Negligence
- D. False imprisonment
Correct Answer: C
Rationale: Failure to notify the provider of a change in a client's condition can be considered negligence.
A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct Answer: B
Rationale: Nausea is a sign of intolerance to enteral feedings, which may also include vomiting and dumping syndrome.
A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation
- B. The client has recently increased their exercise regimen
- C. The client is taking herbal supplements
- D. The client is experiencing increased stress
Correct Answer: A
Rationale: Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications.
A nurse is caring for a client who has a prescription for a narcotic medication. After administration, the nurse is left with an unused portion. What should the nurse do?
- A. Discard the medication in the trash
- B. Return the medication to the pharmacy
- C. Discard the medication with another nurse as a witness
- D. Store the medication for future use
Correct Answer: C
Rationale: Controlled substances should be discarded in the presence of another nurse to ensure accountability.
A nurse is caring for a client who expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct Answer: B
Rationale: Asking the client to describe their feelings allows the nurse to understand the specific concerns and anxieties the client is experiencing.