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A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 101.1°F (37.8°C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct Answer: B
Rationale: Headache and stiff neck, especially with a fever, may indicate meningitis, a life-threatening complication of epidural therapy requiring immediate intervention. Redness, fever, and high pain levels are concerning but less urgent.
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A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet.
Correct Answer: D
Rationale: Placing a washcloth between the skin and tourniquet protects fragile skin in older adults. The other actions are related to vein distension but do not specifically protect the skin.
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
- A. Allergic reaction
- B. Bowel obstruction
- C. Catheter lumen occlusion
- D. Infection
Correct Answer: D
Rationale: Abdominal pain and fever suggest peritonitis, a serious infection related to intraperitoneal therapy. Allergic reactions occur earlier, and bowel obstruction or catheter occlusion present differently.
A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)
- A. Include a review for the need of the device each day in the client's plan of care.
- B. Remind the provider to perform hand hygiene prior to starting the procedure.
- C. Cleanse the preferred site with alcohol and let it dry completely before insertion.
- D. Ask everyone in the room to wear a surgical mask during the procedure.
- E. Plan to complete a sterile dressing change on the device every day.
Correct Answer: A,B,D
Rationale: To prevent infections, daily review of device necessity, hand hygiene, and surgical masks during insertion are critical. Alcohol cleansing must include chlorhexidine for effectiveness, and daily dressing changes are not standard.
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) Patient Blood coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
- A. Unique facility identifier
- B. Lot number related to the donor
- C. Name of the client receiving blood
- D. ABO group and Rh type of the donor
- E. Blood type of the client receiving blood
Correct Answer: A,B,D
Rationale: The ISBT system requires a unique facility identifier, lot number, product code, and ABO/Rh type of the donor. Client-specific information is not included on the blood label.
A nurse is calculating the infusion rate for a medication to be delivered. (Record your answer using a whole number.) drops/min
- A. 10 drops/min
- B. 12 drops/min
- C. 14 drops/min
- D. 16 drops/min
Correct Answer: D
Rationale: The correct infusion rate is 16 drops/min, as specified in the document.