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A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
- A. Stop the IV infusion.
- B. Place a pressure dressing over the IV site.
- C. Apply heat to the client's left hand.
- D. Start a new IV in a different site.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The IV site is showing signs of infiltration (edematous, blanched, cool skin, IV fluid not infusing). Stopping the infusion prevents further harm.
B: Place a pressure dressing over the IV site - A pressure dressing helps reduce swelling and prevent further infiltration.
C: Apply heat to the client's left hand - Applying heat can help improve blood flow and absorption of any infiltrated fluids, aiding in the resolution of the issue.
Summary:
D: Starting a new IV in a different site would be premature without addressing the current issue of infiltration.
E, F, G: No other actions are indicated based on the information provided.
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A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45° angle.
- B. Administer the medication to the client's non-dominant arm.
- C. Pull the client's skin layer downward at administration.
- D. Massage the injection site after administration.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication with the needle at a 45° angle. Enoxaparin is a medication that is typically administered subcutaneously. Injecting at a 45° angle helps ensure proper absorption of the medication into the subcutaneous tissue, avoiding potential intramuscular injection. Administering to the non-dominant arm (B) or pulling the skin downward (C) are not necessary steps for administering enoxaparin. Massaging the injection site after administration (D) is contraindicated as it can increase the risk of bruising or bleeding.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
- A. Is your pain constant or intermittent?
- B. What would you rate your pain on a scale of 0 to 10?
- C. Does the pain radiate?
- D. Is your pain sharp or dull?
Correct Answer: D
Rationale: The correct answer is D: "Is your pain sharp or dull?" This question helps the nurse determine the characteristic of the pain, which is crucial in identifying the underlying cause. Sharp pain is often associated with acute conditions like nerve irritation, whereas dull pain may indicate musculoskeletal issues. Choices A, B, and C are important in pain assessment but do not specifically address the quality of pain. Asking about pain intensity (choice B) or radiation (choice C) can provide valuable information but do not directly address whether the pain is sharp or dull. Therefore, option D is the most appropriate for assessing the quality of the client's pain in this scenario.
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
- A. Combine client care tasks when caring for multiple clients.
- B. Wait until the end of the shift to document client care.
- C. Use the planning step of the nursing process to prioritize client care delivery.
- D. Allow for interruptions in tasks to discuss client care issues with colleagues.
Correct Answer: C
Rationale: Correct Answer: C - Use the planning step of the nursing process to prioritize client care delivery.
Rationale:
1. The planning step involves setting goals, outcomes, and interventions, helping the nurse organize and prioritize care efficiently.
2. Prioritizing care based on client needs ensures critical tasks are addressed first, promoting client safety and well-being.
3. It allows the nurse to allocate time effectively, focusing on urgent and important tasks first.
4. By following the nursing process, the nurse can provide individualized care tailored to each client's specific needs.
Incorrect Choices:
A: Combining tasks can lead to overlooking important details for each client.
B: Waiting to document care can result in errors, omissions, and delays in communication.
D: Allowing interruptions can disrupt workflow and hinder efficient time management.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.