Nokea
The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 mL/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:
- A. Discontinue the infusion.
- B. Apply a warm soak to the site.
- C. Stop the flow of solution temporarily.
- D. Irrigate the needle with normal saline.
Correct Answer: A
Rationale: Swelling and hardness indicate infiltration, requiring immediate discontinuation of the infusion to prevent tissue damage.
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An awake postoperative client received an intravenous regional nerve block (Bier block) in the arm that is now casted and elevated on a pillow. What action should the nurse encourage the client to avoid until sensation returns?
- A. Holding the operated arm close to the face.
- B. Holding the operated arm with the unoperated arm.
- C. Using the unoperated arm.
- D. Using pain medication.
Correct Answer: A
Rationale: Without sensation, holding the arm close to the face risks injury, as the client may not feel pressure or positioning issues. The other actions are safe or unrelated.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
A client with a recent amputation reports phantom limb pain. Which intervention should the nurse implement first?
- A. Administer prescribed gabapentin.
- B. Apply a cold pack to the stump.
- C. Distract the client with music.
- D. Explain the nature of phantom pain.
Correct Answer: D
Rationale: Explaining phantom pain validates the client's experience, addressing anxiety before other interventions.
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)?
- A. Place her in a jacket restraint.
- B. Wrap her hands in soft "mitten" restraints.
- C. Tuck her arms and hands under the drawsheet.
- D. Apply a wrist restraint to each arm.
Correct Answer: B
Rationale: Soft mitten restraints prevent the client from pulling out the I.V. without restricting circulation or increasing ICP, unlike jacket or wrist restraints, which can cause agitation or pressure. Tucking arms under a drawsheet is unsafe and ineffective.
Galactorrhea is caused by overproduction of which hormone?
- A. Prolactin.
- B. Adrenocorticotropic hormone (ACTH).
- C. Growth hormone (GH).
- D. Thyroid-stimulating hormone (TSH).
Correct Answer: A
Rationale: Galactorrhea (inappropriate breast milk production) is caused by excess prolactin, often due to a prolactin-secreting pituitary adenoma.