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After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:
- A. Infection
- B. Infiltration
- C. Phlebitis
- D. Bleeding
Correct Answer: C
Rationale: These symptoms indicate phlebitis, inflammation of the vein.
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The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?
- A. The blood pressure will be elevated.
- B. The pulse will be low.
- C. Temperature will be elevated.
- D. Blood pressure will be low.
Correct Answer: A
Rationale: A 70% hematocrit, abnormally high, increases blood viscosity, elevating blood pressure, not lowering pulse or raising temperature. Nurses monitor this for circulatory strain.
A client receives education on dietary management for ulcerative colitis from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of high-fiber foods.
- B. You should avoid foods containing lactose.
- C. You should decrease your intake of dairy products.
- D. You should increase your intake of dairy products.
Correct Answer: C
Rationale: The correct statement the nurse should include in the teaching is to decrease the intake of dairy products. This is because reducing the intake of dairy products is beneficial in managing symptoms of ulcerative colitis. Dairy products can aggravate symptoms due to their lactose content, thus advising the client to decrease their consumption can help alleviate discomfort and promote better management of the condition.\nChoice A is incorrect because increasing high-fiber foods may worsen symptoms in some individuals with ulcerative colitis.\nChoice B is incorrect as while it is advised to avoid foods containing lactose, this alone does not encompass the full dietary management for ulcerative colitis.\nChoice D is incorrect as increasing the intake of dairy products can exacerbate symptoms in individuals with ulcerative colitis due to their lactose content.
Which of the following statement best describe empathy in nursing?
- A. Judging patient feelings
- B. Understanding patient emotions
- C. A routine task
- D. A legal duty
Correct Answer: B
Rationale: Empathy is understanding patient emotions (B), per nursing e.g., feeling with Mr. Gary. Not judging (A), not routine (C), not legal (D) emotional connection. B best defines empathy's supportive role, enhancing care, making it correct.
Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which of the following is the most appropriate nursing intervention?
- A. Tell the client not to worry until the results are in
- B. Ask the client to express feelings and concern
- C. Reassure the client everything will be alright
- D. Advice the client to divert his attention by watching television and reading newspapers
Correct Answer: B
Rationale: Asking Whitney to express feelings (B) is most appropriate, fostering therapeutic communication, per Rogers. 'Don't worry' (A) and 'everything's alright' (C) dismiss anxiety. Diversion (D) avoids emotions. B addresses her fear, making it correct.
The nurse is caring for a client with a closed head injury. Which finding suggests increasing intracranial pressure?
- A. Pulse rate of 100
- B. Widening pulse pressure
- C. Respiratory rate of 20
- D. Temperature of 99°F
Correct Answer: B
Rationale: Widening pulse pressure (e.g., 140/60) indicates rising intracranial pressure post-head injury, reflecting Cushing's triad with bradycardia and respiratory changes pulse, respiration, or mild fever alone don't confirm this. Nurses report this, signaling brain herniation risk, necessitating urgent intervention like mannitol or surgery.