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A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.
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A nurse is caring for a patient who has a new prescription for prednisone. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for prednisone?
- A. Hypoglycemia
- B. Weight gain
- C. Hypotension
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite. The rationale for this is that prednisone can alter metabolism, leading to redistribution of body fat and increased retention of sodium and water. Monitoring for weight gain is crucial to assess the effectiveness of the medication and to prevent complications such as edema and hypertension.
Regarding the other choices:
A: Hypoglycemia - Prednisone typically causes hyperglycemia, not hypoglycemia.
C: Hypotension - Prednisone can lead to fluid retention and increased blood pressure, not hypotension.
D: Bradycardia - Prednisone does not commonly cause bradycardia; it can actually lead to an increased heart rate.
A nurse assumes various roles while working with patients. Which of the following describes the nursing role of protecting the patient and supporting the patient's decisions? Which role involves protecting and supporting patient decisions?
- A. Advocate
- B. Manager
- C. Caregiver
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Advocate. Nurses act as advocates by protecting the patient's rights, ensuring their voice is heard, and supporting their decisions. Advocacy involves standing up for the patient's best interests and promoting autonomy. The other choices are incorrect because: B: Manager focuses on organizing and coordinating care, C: Caregiver involves providing direct physical and emotional care, and D: Educator focuses on providing information and teaching. Advocacy uniquely encompasses protecting and supporting the patient's decisions, making it the most appropriate choice in this scenario.
A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain. The nurse notes that the patient's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? What condition is indicated by paradoxical chest movement?
- A. Flail chest
- B. Hemothorax
- C. Atelectasis
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest is characterized by a segment of the rib cage that moves independently due to multiple rib fractures. The paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration, is a classic sign of flail chest. This occurs due to the loss of stability in the rib cage, leading to ineffective breathing mechanics.
Incorrect answers:
B: Hemothorax - This is the accumulation of blood in the pleural cavity, which would not cause paradoxical chest movement.
C: Atelectasis - Atelectasis is the collapse of lung tissue, which would not result in paradoxical chest movement.
D: Pneumothorax - Pneumothorax is the presence of air in the pleural space, which typically causes chest pain and shortness of breath but does not result in paradoxical chest movement.
A nurse is educating a parent of a 6-month-old infant about car seat safety. Which statement from the parent indicates a correct understanding of the teaching?,Which statement indicates correct understanding of car seat safety?
- A. Our car seat is an infant model and is anchored in the car.
- B. The car seat is rear-facing in the front passenger seat.
- C. I can fit my hand between the baby and the car seat harness.
- D. Our car seat is front-facing in the back seat.
Correct Answer: A
Rationale: The correct answer is A because anchoring the infant car seat in the car is crucial for safety. This ensures the seat is securely installed and minimizes the risk of injury during a collision. Choice B is incorrect as rear-facing car seats should never be placed in the front passenger seat due to the presence of airbags, which can be dangerous for infants. Choice C is incorrect because the harness should be snug against the infant's body without any slack, and being able to fit a hand between the harness and the baby indicates it is too loose. Choice D is incorrect as infants should be in rear-facing seats until at least 2 years old for optimal safety.
A nurse is admitting a patient exhibiting manic behavior. The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse's priority action? What is the priority action for a manic patient?
- A. Encourage self-care.
- B. Assist the patient in identifying coping behaviors.
- C. Prevent self-directed violence.
- D. Identify support systems.
Correct Answer: C
Rationale: The correct answer is C: Prevent self-directed violence. When dealing with a manic patient, the priority action should always be to ensure the safety of the patient and others. Manic episodes can lead to impulsive and risky behaviors, including self-harm or suicide attempts. By prioritizing the prevention of self-directed violence, the nurse can address the immediate threat to the patient's well-being. Encouraging self-care (choice A) and identifying coping behaviors (choice B) are important aspects of care but may not be the most urgent in this situation. Identifying support systems (choice D) is also valuable but does not address the immediate safety concerns presented by the manic behavior.