Nokea
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
- A. Administer topical lidocaine to the site.
- B. Place warm compresses on the site.
- C. . Administer prescribed oral pain medication.
- D. Massage the site with scented oils.
Correct Answer: B
Rationale: The correct answer is B: Place warm compresses on the site. Warm compresses can help increase blood flow, reduce pain, and promote healing at the site of inflammation. The warmth can help dilate blood vessels, increasing circulation to the area and promoting the removal of inflammatory substances. This can help alleviate pain and reduce swelling. Administering topical lidocaine (choice A) may not address the underlying cause of pain and redness. Administering oral pain medication (choice C) may be necessary for severe pain but may not directly address the local inflammation. Massaging the site with scented oils (choice D) can potentially introduce more irritants and should be avoided in cases of inflammation.
You may also like to solve these questions
A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a
more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water
intravenously?
- A. Never, because it rapidly enters red blood cells, causing them to rupture.
- B. When the patient is severely dehydrated resulting in neurologic signs and symptoms
- C. When the patient is in excess of calcium and/or magnesium ions
- D. When a patients fluid volume deficit is due to acute or chronic renal failure
Correct Answer: A
Rationale: The correct answer is A because electrolyte-free water, such as sterile water, can rapidly enter red blood cells due to osmotic differences, causing them to swell and potentially rupture, leading to hemolysis. This can result in severe harm to the patient.
Choice B is incorrect because electrolyte-free water is not indicated for severely dehydrated patients with neurologic signs and symptoms. They require electrolytes to correct their imbalances.
Choice C is incorrect as administering electrolyte-free water would not address excess calcium and/or magnesium ions in the body. Specific treatments for hypercalcemia or hypermagnesemia are needed.
Choice D is incorrect because patients with fluid deficits due to renal failure require electrolyte-balanced solutions to manage their condition effectively. Electrolyte-free water would not address the electrolyte imbalances associated with renal failure.
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Increased PaCO2
- D. CNS disturbances
Correct Answer: B
Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.
A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial
blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg.
What does the ABG reflect?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. A low pH (7.21) indicates acidosis. The elevated PaCO2 (64 mm Hg) indicates respiratory acidosis, as high CO2 levels lead to carbonic acid formation, decreasing pH. The normal HCO3 (24 mm Hg) suggests compensation for the respiratory acidosis. Other choices are incorrect as they do not align with the ABG values provided. Metabolic alkalosis (B) would have a high pH and HCO3, respiratory alkalosis (C) would have a high pH and low PaCO2, and metabolic acidosis (D) would have a low pH and HCO3.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
- A. Encourage oral fluid intake.
- B. Connect the client to a cardiac monitor.
- C. Assess urinary output.
- D. Administer oral calcitonin (Calcimar).
Correct Answer: A
Rationale: The correct answer is A: Encourage oral fluid intake. When a client has hypercalcemia (serum calcium level of 14 mg/dL), the priority is to increase fluid intake to promote renal calcium excretion. This helps prevent complications such as renal calculi. The first step is to dilute the serum calcium by increasing fluid intake, which can help lower the serum calcium level. Connecting the client to a cardiac monitor (B) is not the priority as hypercalcemia affects the kidneys more than the heart. Assessing urinary output (C) is important but encouraging fluid intake is more immediate. Administering oral calcitonin (Calcimar) (D) is not the first action as it is a medication used for long-term management of hypercalcemia, not the immediate priority.
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
- A. Urine output of 25 mL/hr
- B. Serum potassium level of 5.4 mEq/L
- C. Blood osmolality of 250 mOsm/L
Correct Answer: A
Rationale: Step-by-step rationale for why option A is correct:
1. Inhibition of aldosterone secretion leads to decreased sodium reabsorption and increased water excretion.
2. Decreased aldosterone can result in decreased blood volume and BP, leading to decreased urine output.
3. Monitoring urine output is crucial to assess renal function and fluid balance.
4. A urine output of 25 mL/hr is considered inadequate and can indicate renal impairment or dehydration.
Summary:
Option A is correct as it directly relates to the mechanism of action of inhibiting aldosterone secretion. Options B, C, and D are incorrect as they do not align with the expected complications of aldosterone inhibition.