Nokea
During a bed bath, the nurse observes that a client's IV site is red and swollen. What should the nurse do first?
- A. Discontinue the IV under physician's guidance
- B. Apply a warm compress to the site
- C. Notify the physician
- D. Document the appearance of the site and continue the bath
Correct Answer: C
Rationale: The correct first action when a nurse observes a red and swollen IV site during a bed bath is to notify the physician. This is crucial because prompt reporting allows for immediate intervention to prevent further complications. Discontinuing the IV (Choice A) should only be done under the physician's guidance to avoid any adverse effects and ensure proper care. Applying a warm compress (Choice B) may not address the underlying issue and could potentially worsen the situation if the cause is an infection or infiltration. Documenting the site's appearance and continuing the bath (Choice D) without immediate action might delay necessary treatment, leading to potential complications.
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The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads, 'Ilosone 100mg/5mL.' How many mL should the nurse administer at each dose?
- A. 15 mL
- B. 10 mL
- C. 20 mL
- D. 5 mL
Correct Answer: A
Rationale: To determine the volume of medication needed for a 300 mg dose of Ilosone (100mg/5mL), we set up a proportion: 100 mg is to 5 mL as 300 mg is to x mL. Cross-multiplying, we get x = (300*5)/100 = 15 mL. Therefore, the nurse should administer 15 mL at each dose. Choice B (10 mL) is incorrect as it does not reflect the correct calculation based on the medication concentration. Choices C (20 mL) and D (5 mL) are also incorrect as they do not accurately calculate the volume required for the prescribed dose.
When caring for a client with a tracheostomy, what is the most important assessment to perform?
- A. Check the client's oxygen saturation
- B. Assess the tracheostomy site for signs of infection
- C. Monitor the client's respiratory rate
- D. Ensure the tracheostomy ties are secure
Correct Answer: A
Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.
A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?
- A. Instruct the client to sit or lie down
- B. Monitor blood pressure and pulse
- C. Administer an anti-dizziness medication
- D. Increase fluid intake
Correct Answer: B
Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.
The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?
- A. The client should bottle feed and pump her breast for 3 days following immunization
- B. The vaccine is given to produce maternal antibodies before lactation occurs
- C. The infant will receive immunization through the mother's breast milk
- D. The client should not get pregnant for 3 months after immunization
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a community health fair, a nurse is providing education on the effects of smoking. What is the most important information to include?
- A. Smoking can lead to cosmetic issues like tooth staining.
- B. Smoking is a leading cause of preventable death worldwide.
- C. Smoking temporarily elevates mood and alertness.
- D. Smoking is an expensive habit.
Correct Answer: B
Rationale: The correct answer is B: 'Smoking is a leading cause of preventable death worldwide.' This information is crucial as it highlights the severe health risks associated with smoking, emphasizing the importance of cessation for overall health. Choice A is incorrect because cosmetic issues like tooth staining are not as significant as the life-threatening consequences of smoking. Choice C is incorrect because although smoking may temporarily elevate mood and alertness due to nicotine, this does not outweigh the serious health implications. Choice D is incorrect as while smoking is indeed an expensive habit, the focus should be on the health-related consequences to stress the urgency of quitting.