Nokea
The client has an IV in place when he returns for surgery. While examining the IV site, the licensed practical nurse notices pallor, coolness, and edema. The nurse is aware that these are signs of:
- A. Infiltration
- B. Infection
- C. Thrombus formation
- D. Sclerosing of the vein
Correct Answer: A
Rationale: Pallor, coolness, and edema at an IV site indicate infiltration, where IV fluid leaks into surrounding tissue. Infection shows redness and warmth, thrombus formation may cause pain and redness, and sclerosing involves vein hardening, not edema.
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During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
- A. Compare current mental status to previous findings
- B. Encourage the client to ambulate in the hallway
- C. Hold the client's morning dose of lactulose
- D. Monitor the client's ammonia level
- E. Observe the client's hand movements with the arms extended
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.
A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?
- A. An 18 month-old who ate an undetermined amount of crystal drain cleaner
- B. A 14 month-old who chewed 2 leaves of a philodendron plant
- C. A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
- D. A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
Correct Answer: A
Rationale: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Orange juice is acidic and will help neutralize the alkaline drain cleaner.
Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L)
The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?
- A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
- B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
- C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
- D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty
Correct Answer: A
Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.
The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.
- A. Dress the infant in warm clothing and blankets
- B. Encourage smaller, frequent feedings
- C. Intervene quickly to prevent the infant from crying excessively
- D. Promote a quiet period on waking in the morning
- E. Turn the infant frequently during sleep
Correct Answer: B,C,D
Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.
A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Administer oxygen via non-rebreather mask
- B. Apply an occlusive dressing over the insertion site
- C. Assist the client to high Fowler position
- D. Monitor vital signs and respiratory effort
- E. Notify the health care provider
Correct Answer: A,B,D,E
Rationale: Oxygen, occlusive dressing, vital sign monitoring, and provider notification address air embolism risk and hypoxia. High Fowler may worsen air entry; semi-Fowler is preferred.