Nokea
A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?
- A. Bruising at the IV site
- B. Edema at the IV site
- C. Warmth along the IV site
- D. Pallor at the IV site
Correct Answer: B
Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.
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A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?
- A. Cut toenails straight across
- B. Wear shoes at all times
- C. Soak feet in hot water daily
- D. Apply lotion between the toes
Correct Answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.
A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?
- A. Measure the residual gastric volume
- B. Verify tube placement
- C. Flush the tube with 100 mL of water
- D. Administer the feeding in small boluses
Correct Answer: B
Rationale: Verifying tube placement is the crucial initial step a nurse should take before administering enteral feedings through an NG tube. This step ensures that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Measuring residual gastric volume, flushing the tube with water, or administering the feeding in small boluses are all important steps in enteral feeding but should only be done after confirming the correct tube placement.
A healthcare professional is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the professional include?
- A. Inhale for 1 second
- B. Shake the inhaler vigorously
- C. Hold the inhaler 5-7 cm away from the mouth
- D. Hold breath for 5 seconds after inhalation
Correct Answer: B
Rationale: The correct instruction when using a metered-dose inhaler (MDI) is to shake the inhaler vigorously before use. Shaking the inhaler ensures proper mixing of the medication, which is crucial for effective delivery of the medication into the lungs. Inhaling for a specific duration, holding the inhaler at a certain distance from the mouth, or holding the breath after inhalation are not as critical as ensuring proper mixing of the medication by shaking the inhaler.
A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct Answer: B
Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.
A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?
- A. Irrigate the catheter with normal saline
- B. Notify the provider
- C. Assess for signs of infection
- D. Administer prescribed antibiotics
Correct Answer: B
Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.