Nokea
While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
- A. Aspirate the IV site for blood return.
- B. Slow the infusion.
- C. Inspect the IV site.
- D. Stop the infusion.
Correct Answer: C
Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
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Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
- A. Stay with the client, remove the dressing, and elevate the head of bed.
- B. Call a code, open the trach set, and position the client supine.
- C. Have the client say "EEE"? to check for laryngeal integrity.
- D. Immediately go to the nurse's station and call the physician
Correct Answer: A
Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.
Which client should be seen first by the Emergency Department nurse?
- A. A six-year-old with a femur fracture.
- B. A two-year-old with a fever of 102 degrees F.
- C. A three-year-old with wheezes in the right lower lobe.
- D. A two-year-old whose gastrostomy tube came out.
Correct Answer: C
Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.
While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
- A. Recommend a dermatological consult to the physician.
- B. Note the location of the mole and contact the physician via telephone.
- C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
- D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.
Correct Answer: C
Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.
A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?
- A. Call the surgeon immediately.
- B. Administer Extra Strength Tylenol per orders.
- C. Assess the surgical site.
- D. Offer extra blankets and increase fluids.
Correct Answer: A
Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4°F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.
The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?
- A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
- B. Have the other staff gather additional information on the tardy staff member
- C. Call the staff nurse in for an interview to investigate the problem and possible solutions
- D. Assign a mentor to assist the staff member in arriving on time
Correct Answer: C
Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.