Nokea
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.
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A nurse is caring for a client who is receiving IV chemotherapy. Which of the following actions should the nurse take?
- A. Check the IV site for redness or swelling.
- B. Administer the chemotherapy through a peripheral IV line.
- C. Monitor the client's blood pressure every 4 hr.
- D. Instruct the client to avoid drinking water during infusion.
Correct Answer: A
Rationale: Checking for redness or swelling detects extravasation early, critical for chemotherapy safety. Central lines are preferred, blood pressure checks are routine, and hydration is encouraged.
A nurse is caring for a client who is postoperative following a lumbar laminectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate with a straight back.
- B. Instruct the client to avoid turning at the waist.
- C. Allow the client to sit in a chair for 2 hr at a time.
- D. Apply a heating pad to the surgical site.
Correct Answer: B
Rationale: Avoiding waist turning prevents strain on the surgical site. Ambulation should allow natural posture, prolonged sitting risks stiffness, and heating pads may increase swelling.
A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Insert an oral airway into the client's mouth.
- B. Lower the side rails of the bed when the seizure begins.
- C. Measure the duration of the seizure.
- D. Restrain the client's arms and legs to prevent injury.
Correct Answer: C
Rationale: Measuring seizure duration aids in assessing severity and guiding treatment. Inserting airways, lowering rails, or restraining can cause injury or complications.
A nurse is assisting with the care of a client who is at 38 weeks of gestation and in active labor. Which of the following actions should the nurse take?
- A. Apply counterpressure to the client's sacrum during contractions.
- B. Position the client in a supine position during contractions.
- C. Encourage the client to take deep, cleansing breaths between contractions.
- D. Administer oxygen at 2 L/min via nasal cannula during contractions.
Correct Answer: C
Rationale: Deep breaths between contractions promote relaxation and oxygenation. Counterpressure may help some, supine position risks vena cava compression, and oxygen isn't routinely needed.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation?
- A. Place a wedge pillow between the client's legs.
- B. Encourage the client to sit in a recliner.
- C. Allow the client to cross their legs when seated.
- D. Instruct the client to bend at the waist when picking up objects.
Correct Answer: A
Rationale: A wedge pillow maintains abduction, preventing hip dislocation. Recliners, leg crossing, or bending at the waist increase dislocation risk.