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A nurse is caring for a client who is receiving IV fluids. The nurse notes that the IV site is red and swollen. Which of the following actions should the nurse take first?
- A. Elevate the extremity.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: Discontinuing the IV line is the first action to prevent further complications from infiltration or phlebitis at the red and swollen site.
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A nurse is reinforcing teaching with a client who has a new prescription for a progesterone injection. Which of the following instructions should the nurse include?
- A. Inject into the thigh.
- B. Rotate injection sites.
- C. Store the medication in the refrigerator.
- D. Massage the site after injection.
Correct Answer: B
Rationale: Rotating injection sites for progesterone injections prevents tissue irritation and ensures consistent absorption.
A nurse is caring for a client who has a new diagnosis of gout. Which of the following dietary recommendations should the nurse make?
- A. Limit purine-rich foods.
- B. Increase dairy intake.
- C. Avoid whole grains.
- D. Reduce fluid intake.
Correct Answer: A
Rationale: Limiting purine-rich foods, like red meat and shellfish, reduces uric acid production, helping manage gout.
A nurse is collecting data from a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following findings should the nurse expect?
- A. The client reports a tightening of her abdomen.
- B. The client reports increased urinary output.
- C. The client reports a temperature of 38.9°C (102°F).
- D. The client reports seeing bright red blood.
Correct Answer: A
Rationale: A tightening of the abdomen indicates uterine contractions, a hallmark of preterm labor, which the nurse should expect at 32 weeks of gestation.
A nurse is reinforcing teaching with a client who is scheduled for a bronchoscopy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to fast for 6 to 8 hours before the procedure.
- B. I can drive myself home after the procedure.
- C. I will receive general anesthesia during the procedure.
- D. I should avoid gargling after the procedure.
Correct Answer: A
Rationale: Fasting for 6 to 8 hours before a bronchoscopy reduces the risk of aspiration during the procedure.
A nurse is caring for a client who has a new prescription for gabapentin. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Gabapentin commonly causes drowsiness, which can affect the client's alertness and safety.