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A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- A. The area surrounding the insertion site feels warm to the touch.
- B. The infusion rate has stopped but the tubing is not kinked.
- C. There is fluid leaking around the insertion site.
- D. There is no blood return when the tubing is aspirated.
Correct Answer: A
Rationale: The correct answer is A because warmth at the insertion site is a classic sign of phlebitis, indicating inflammation of the vein. This is due to irritation from the IV catheter. Choice B is incorrect because the infusion rate stopping is not specific to phlebitis. Choice C is incorrect as fluid leaking suggests an issue with the dressing or the catheter. Choice D is incorrect as no blood return could indicate a clot but not necessarily phlebitis.
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A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
- A. Serosanguineous drainage.
- B. Mild erythema.
- C. Warmth.
- D. Fever.
Correct Answer: D
Rationale: The correct answer is D: Fever. Infection at the pin sites in skeletal traction can lead to systemic signs such as fever. Fever is a common indicator of infection as the body responds to pathogens by increasing its temperature. Serosanguineous drainage, mild erythema, and warmth can be normal findings in the early stages of healing or due to inflammation, but fever indicates a more serious underlying issue like infection. Therefore, the nurse should prioritize monitoring for fever to promptly identify and address any potential infection.
The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?
- A. Red skin with edema in the nail beds.
- B. Black fingertips surrounded by an erythematous rash.
- C. A white appearance to the skin that is insensitive to touch.
- D. A pink edematous hand.
Correct Answer: C
Rationale: The correct answer is C: A white appearance to the skin that is insensitive to touch. Frostbite initially presents with a white or pale appearance due to vasoconstriction, followed by numbness or insensitivity to touch. This occurs as a result of decreased blood flow to the affected area. As frostbite progresses, the skin may turn blue or purplish due to tissue damage. Red skin with edema in the nail beds (Choice A) is more indicative of inflammation or infection rather than frostbite. Black fingertips surrounded by an erythematous rash (Choice B) may suggest gangrene, a severe complication of untreated frostbite. A pink edematous hand (Choice D) is not characteristic of frostbite, as it typically presents with a white or bluish discoloration.
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Fever usually accompanies myocardial infarction.
- B. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
- C. Headache is a common side effect of nitrates.
- D. Acetaminophen potentiates the therapeutic effect of nitrates.
- E. Acetaminophen potentiates the therapeutic effect of nitrates.
Correct Answer: C
Rationale: The correct answer is C. Headache is a common side effect of nitrates. Nitroglycerin, a common topical nitrate, is often prescribed for angina to dilate blood vessels and improve blood flow to the heart. One common side effect of nitrates is headache due to vasodilation, and acetaminophen is often prescribed to help alleviate this headache. Choices A and B are incorrect as they do not directly relate to why acetaminophen is prescribed with nitrates. Choice D is incorrect because acetaminophen does not potentiate the therapeutic effect of nitrates, it only helps with headache relief. Choice E is a duplicate of D.
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
- A. Use friction when washing the affected area.
- B. Use a new cosmetic pad with each limited application of makeup.
- C. Use an oil-based soap to wash affected areas daily.
- D. Express the larger comedones periodically.
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin. Choice A is incorrect because friction can irritate the skin and worsen acne. Choice C is incorrect as oil-based soap can clog pores and worsen acne. Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.