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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.
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A nurse is caring for a client who is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild bruising.
- B. The client's aPTT is 90 seconds.
- C. The client's blood pressure is 122/80 mm Hg.
- D. The client's urine output is 40 mL/hr.
Correct Answer: B
Rationale: An aPTT of 90 seconds (above therapeutic range of 60-80) suggests excessive anticoagulation, requiring reporting. Bruising, normal BP, and urine output are less urgent.
A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
- A. You should lay down for 1 hour following a meal.
- B. You should eat three large meals and two snacks per day.
- C. You should only drink 2 cups of coffee per day.
- D. You should elevate the head of the bed while sleeping.
Correct Answer: D
Rationale: Elevating the bed head prevents acid reflux at night. Lying down post-meal, large meals, or coffee can worsen GERD symptoms.
A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.
- A. Discarding worksheets containing client information in a wastebasket
- B. Writing a client's diagnosis on the message board in the client's room
- C. Giving change of shift report to a nurse outside the client's room
- D. Discussing a client's prognosis with an assistive personnel who is caring for the client
Correct Answer: C
Rationale: Giving a shift report in a private setting prevents unauthorized individuals from overhearing, protecting confidentiality. Discarding worksheets improperly, writing diagnoses publicly, or discussing prognosis openly risks breaches.
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. Medical health insurance claims
- C. Physical assessment findings
- D. Medications taken prior to admission
Correct Answer: C
Rationale: Physical assessment findings like mobility or pain are critical for a physical therapist to develop a tailored plan. Family history, insurance, or past medications are less relevant.
A nurse is caring for a client who has a new prescription for heparin. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Heparin's anticoagulant effect is monitored via PTT to ensure therapeutic dosing. Potassium, hemoglobin, or BUN aren't directly affected by heparin.