Nokea
A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
- A. Nerve damage
- B. Infection
- C. Infiltration
- D. Phlebitis
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.
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A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?
- A. Refill the prescription every 12 months.
- B. Take a second tablet after 5 min for unrelieved chest pain.
- C. Swallow the tablet whole with a glass of water.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Taking a second dose after 5 minutes for unrelieved pain is standard protocol for nitroglycerin, which is taken sublingually, not swallowed, and stored at room temperature, refilled every 6 months.
A nurse is collecting data from a female client who is postmenopausal. Which of the following findings should the nurse identify as a risk factor for the development of osteoporosis?
- A. Congenital heart murmur
- B. Long-term use of prednisone
- C. Monthly vitamin Bâ‚â‚‚ injections
- D. History of kidney stones
Correct Answer: B
Rationale: Osteoporosis risk rises postmenopause due to estrogen loss, but long-term prednisone use accelerates bone loss by inhibiting osteoblast activity and calcium absorption, a well-established glucocorticoid effect. Congenital heart murmur affects circulation, not bone density, unless activity is severely limited, which isn't implied. Vitamin Bâ‚â‚‚ injections treat deficiency, indirectly supporting bone health via red cell production, not increasing risk. Kidney stones relate to calcium metabolism but don't directly cause osteoporosis unless chronic disease alters bone remodeling, an uncommon link here. Prednisone's impact is direct, dose-dependent, and significant often warranting bisphosphonates making it the standout risk factor to identify, per osteoporosis screening guidelines (e.g., NOF), for preventive planning.
48
A nurse is reinforcing bladder management instructions with a client who has urinary incontinence. Which of the following statements by the client indicates an understanding?
- A. I should use the bathroom at set times during the day.
- B. I can continue to drink coffee every day.
- C. I can insert a catheter in my bladder at bedtime.
- D. I should stop drinking fluids an hour before bedtime.
- E. I'll avoid pelvic floor exercises.
- F. I can drink alcohol freely.
- G. I should ignore urges to urinate.
Correct Answer: A
Rationale: Scheduled voiding helps manage incontinence; coffee and alcohol worsen it, and self-catheterization isn't routine.
44
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Clamp the catheter tubing distal to the sampling port for 15 min.
- B. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Empty the urine into a sterile container labeled with the client identifiers.
- E. Document in the client's electronic medical record that the specimen was sent to the laboratory
- F. Wash hands before starting.
- G. Check the client's ID band.
Correct Answer:
Rationale: Clamping allows urine to collect, wiping ensures sterility, aspirating collects the sample, transferring maintains sterility, and documenting completes the process.
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
- A. I can have clear liquids up to 3 hours before the procedure.
- B. I can eat as soon as the procedure is completed.
- C. I will receive an injection of radioactive material prior to having the procedure.
- D. I might have blood-tinged sputum after the procedure.
Correct Answer: D
Rationale: Blood-tinged sputum is normal post-bronchoscopy due to airway irritation, showing understanding. Clear liquids stop earlier, eating waits until gag reflex returns, and no radiation is involved.