Nokea
A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?
- A. Redness at the site
- B. Warmth around the site
- C. Edema
- D. Pain at the site
Correct Answer: C
Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration.
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A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct Answer: A
Rationale: Placing the client on their side with their head forward helps maintain an open airway and prevents aspiration.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct Answer: C
Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.
A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skills should the nurse expect?
- A. Walks without assistance using a wide stance
- B. Climbs stairs with assistance
- C. Runs smoothly
- D. Kicks a ball forward
Correct Answer: A
Rationale: At 15 months, toddlers typically walk independently but may do so with a wide stance for balance.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.
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. Continue the infusion
- B. Increase the infusion rate
- C. Discontinue the infusion
- D. Apply a cold compress
Correct Answer: C
Rationale: The symptoms suggest phlebitis. The nurse should discontinue the infusion and may apply a warm compress.