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The nurse notes that the skin around the catheter's insertion site is edematous and cool.
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. Document the infiltration
- B. Apply a warm compress
- C. Elevate the arm
- D. Stop the infusion
Correct Answer: D
Rationale: Stopping the infusion prevents further fluid extravasation.
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A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?
- A. Administer an antibiotic medication.
- B. Cleanse skin eruptions with povidone-iodine.
- C. Avoid over-the-counter topical ointments.
- D. Place disposable thermometers in the client's room.
Correct Answer: C
Rationale: Avoiding OTC ointments prevents irritation or delayed healing in herpes simplex outbreaks.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
- A. Voice alteration
- B. Neck pain
- C. Tingling of the scalp
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect post-ECT.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.
A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching?
- A. Carry your newborn back to the nursery in your arms when you need to rest.
- B. Request that the nurses show their nursing license prior to removing your newborn from the room.
- C. Alert the staff if any of your newborn's identification bands are missing.
- D. Leave your newborn in the bassinet in your room while you use the bathroom.
Correct Answer: C
Rationale: Missing ID bands increase abduction risk, requiring immediate staff notification.
The client has pyelonephritis and is receiving gentamicin via IV infusion.
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?
- A. New onset of hearing loss
- B. Slurred speech
- C. Constipation
- D. Hypotension
Correct Answer: A
Rationale: Gentamicin can cause ototoxicity, leading to hearing loss.