Nokea
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Elevate the arm.
- B. Document the infiltration.
- C. Stop the infusion.
- D. Apply a warm compress.
Correct Answer: C
Rationale: Stopping the infusion is the priority to prevent further fluid infiltration, which can cause tissue damage. Elevation, documentation, and compresses follow after halting the infusion.
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A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings should the nurse report to the provider?
- A. The client reports a headache.
- B. The client's pupils are unequal.
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/85 mm Hg.
Correct Answer: B
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration, requiring reporting. Headache, minimal drainage, and normal BP are less urgent.
A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote arm mobility?
- A. Encourage the client to perform deep breathing exercises.
- B. Instruct the client to avoid using the affected arm for 6 weeks.
- C. Teach the client to perform range-of-motion exercises daily.
- D. Apply a compression bandage to the affected arm.
Correct Answer: C
Rationale: Daily range-of-motion exercises prevent stiffness and promote mobility. Breathing exercises, arm avoidance, or compression don't target mobility.
A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following statements should the nurse include?
- A. You will be given a sedative during the procedure.
- B. You can eat a light breakfast the morning of the procedure.
- C. You will need to maintain a clear liquid diet for 3 days prior to the procedure.
- D. You will need to take an antibiotic before the procedure.
Correct Answer: A
Rationale: A sedative is used to ensure comfort during a colonoscopy. Clear liquids are required only 1-2 days prior, no food is allowed the morning of, and antibiotics aren't standard.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent phlebitis?
- A. Change the IV site every 72 to 96 hr.
- B. Massage the IV site gently every 4 hr.
- C. Apply a cold compress to the IV site.
- D. Use a large-gauge catheter for fluid administration.
Correct Answer: A
Rationale: Changing the IV site every 72-96 hours reduces infection and phlebitis risk. Massaging, cold compresses, or large catheters don't prevent phlebitis.
A nurse is caring for a client who is postoperative following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports a frequent urge to urinate.
- B. The client's urine is pink-tinged.
- C. The client's bladder irrigation fluid is clear.
- D. The client's urine output contains large clots.
Correct Answer: D
Rationale: Large clots in urine suggest hemorrhage, requiring immediate reporting. Urge to urinate, pink-tinged urine, and clear irrigation fluid are expected post-TURP.