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A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
- A. Apply pressure to the venipuncture site with sterile gauze.
- B. Perform hand hygiene.
- C. Clamp the IV tubing.
- D. Withdraw the catheter from the client's vein.
- E. Remove the dressing and tape from the venipuncture site.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.
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A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client consumed citrus juice 3 days before the test.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can irritate the gastrointestinal tract and cause minor bleeding, potentially leading to a false-positive fecal occult blood test result.
A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
- A. Obtain the client's peak expiratory flow volume.
- B. Encourage the client to cough.
- C. Place the client in a semi-Fowler's position.
- D. Encourage the client to use a straw to sip cool liquids.
Correct Answer: C
Rationale: Placing the client in a semi-Fowler's position promotes airway clearance and comfort post-tonsillectomy, especially with an SpO2 of 93%.
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
- A. Trendelenburg with legs extended
- B. Supine with knees flexed
- C. Semi-Fowler's with legs extended
- D. Left-lateral with knees flexed
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
- D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
Correct Answer: C
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range, increasing the risk of bleeding during a liver biopsy, and should be reported to the provider.
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Each finding might support more than 1 disease process.
- A. Dyspnea
- B. Increased pain at incision site
- C. Tingling sensation to right foot
- D. Swelling at incision site
Correct Answer: A (fat embolism syndrome), B (acute compartment syndrome, infection), C (acute compartment syndrome), D (acute compartment syndrome, infection)
Rationale: Dyspnea is typical of fat embolism; increased pain and swelling suggest compartment syndrome or infection; tingling indicates compartment syndrome.