Nokea
The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washcloth over the site.
Correct Answer: B
Rationale: The first action should be to discontinue the intravenous line to prevent further complications such as infection or thrombophlebitis. Starting a new IV in the right hand is not the priority as addressing the current issue is important. Completing an incident record can be done after addressing the immediate concern of the IV site. Placing a warm washcloth over the site does not address the red streak and tenderness, which may indicate an infection that requires discontinuation of the IV line.
You may also like to solve these questions
Which of the following actions by the healthcare provider would be considered false imprisonment?
- A. The healthcare provider tells the client they are not allowed to leave until the physician has released them.
- B. The healthcare provider asks the client why they wish to leave.
- C. The healthcare provider asks the client to explain what they understand about their medical diagnosis.
- D. The healthcare provider asks the client to sign an against medical advice discharge form.
Correct Answer: A
Rationale: The correct answer is A. False imprisonment occurs when a healthcare provider restrains a client from leaving against their will, even if the provider believes it is in the client's best interest. In this scenario, telling the client they are not allowed to leave until the physician has released them constitutes false imprisonment as it restricts the client's freedom of movement. Choice B is incorrect because asking the client why they wish to leave is a form of assessment and does not involve restraining the client. Choice C is incorrect as it pertains to educating the client about their medical condition. Choice D is incorrect because asking the client to sign an against medical advice discharge form is a legal and ethical procedure to ensure the client understands the risks of leaving against medical advice.
Which of the following is true about effective leadership?
- A. Leadership traits can be learned through experience and reflection.
- B. Nurses can learn to become good leaders by acting as good leaders and reflecting on leadership qualities they have and those they can improve upon.
- C. Focus on leadership activities required for the day is essential for effective leadership.
- D. Taking advantage of every opportunity to be a leader is crucial, creating those opportunities as often as possible, especially after gaining experience as a nurse.
Correct Answer: B
Rationale: Choice B is correct because nurses can develop effective leadership skills by actively engaging as good leaders and reflecting on their existing leadership qualities and areas for improvement. This process of self-assessment and continuous improvement is crucial in becoming a successful leader. Choice A is incorrect as leadership traits can be learned through experience and reflection rather than being impossible to acquire from a book. Choice C is incorrect as effective leadership involves focusing on long-term goals and strategies, not just daily activities. Choice D is incorrect because while seizing leadership opportunities is important, it should be done strategically and with a solid foundation of experience in nursing to ensure successful leadership outcomes.
A client with Cushing's syndrome is being assessed by the nurse. Which of the following clinical manifestations is consistent with this condition?
- A. Moon face
- B. Weight loss
- C. Hyperpigmentation
- D. Hypotension
Correct Answer: A
Rationale: The correct clinical manifestation consistent with Cushing's syndrome is a 'moon face.' Cushing's syndrome is characterized by fat redistribution, leading to the round and full appearance of the face known as a moon face. Choice B, weight loss, is not common in Cushing's syndrome as patients often experience weight gain. Choice C, hyperpigmentation, is more indicative of Addison's disease, not Cushing's syndrome. Choice D, hypotension, is not typically associated with Cushing's syndrome which often presents with hypertension due to excess cortisol.
A client with hyperparathyroidism is being assessed. Which of the following symptoms is the nurse likely to find?
- A. Tetany
- B. Hypocalcemia
- C. Bone pain
- D. Hypotension
Correct Answer: C
Rationale: In hyperparathyroidism, there is excessive production of parathyroid hormone, leading to increased calcium resorption from the bones. This process causes bone pain, making choice C the correct answer. Tetany (choice A) is associated with hypocalcemia, not hyperparathyroidism. Hypocalcemia (choice B) is the opposite condition of hyperparathyroidism, where blood calcium levels are elevated. Hypotension (choice D) is not a typical symptom of hyperparathyroidism.
The client with newly diagnosed diabetes mellitus is receiving education from the nurse on managing blood glucose levels. Which statement indicates a need for further teaching?
- A. I will monitor my blood glucose levels regularly.
- B. I can eat whatever I want as long as I take my medication.
- C. I should exercise regularly to help control my blood sugar.
- D. I will rotate my injection sites to avoid tissue damage.
Correct Answer: B
Rationale: Choice B indicates a need for further teaching because it suggests that the client can eat whatever they want as long as they take their medication, which is incorrect. Clients with diabetes mellitus need to follow a healthy and balanced diet in addition to taking their medication to effectively manage blood glucose levels. Choices A, C, and D are correct statements for managing diabetes. Monitoring blood glucose levels regularly, engaging in regular exercise to help control blood sugar, and rotating injection sites to avoid tissue damage are all important aspects of diabetes management.