Nokea
The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?
- A. Phlebitis
- B. Infection
- C. Infiltration
- D. Thrombosis
Correct Answer: C
Rationale: The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV. All the remaining options are likely to be accompanied by warmth at the site.
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The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?
- A. Do you have concerns about managing your condition?'
- B. Do you think you might need to go to the nursing home?'
- C. If you take the correct medications, I doubt this will happen again.'
- D. Don't worry. I'm sure your family will provide all the help you need.'
Correct Answer: A
Rationale: The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in the correct option. Option 2 is not an appropriate nursing response because it is making suggestions regarding care options without appropriately identifying the client's true concerns. Options 3 and 4 provide inappropriate false hope and disregard the client's concerns.
The nurse is providing education to the unlicensed assistive personnel (UAP) in preparation for communicating with a hearing-impaired client? Which statements by the UAP indicates that teaching has been effective? Select all that apply.
- A. Speak using a normal tone of voice.'
- B. Speak clearly when communicating with the client.'
- C. Speak slowly and directly into the client's impaired ear.'
- D. Face the client directly when carrying on a conversation.'
- E. Be aware of signs that the client does not understand the conversation.'
Correct Answer: A,B,D,E
Rationale: When communicating with a hearing-impaired client, the caregiver should speak in a normal tone to the client and should not shout. One should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is being said, the caregiver should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but one must avoid talking directly into the impaired ear.
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
- A. Elevating the affected leg is indicated.'
- B. Keeping the affected leg flat encourages healing.'
- C. Engaging in activity as tolerated should be encouraged.'
- D. Maintaining bathroom privileges is the most important action.'
Correct Answer: A
Rationale: The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart, decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bed rest.
After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client's need to ambulate?
- A. What is it about getting out of bed that concerns you?'
- B. If you are afraid of the pain, I can give you medication to help.'
- C. If you don't get up and start walking, your recovery will take much longer.'
- D. Being dependent on others must be a depressing for an active person like yourself.'
Correct Answer: A
Rationale: Early ambulation during the postoperative period is very important to a client's health and recovery, but many different factors may be contributing to the client's refusal to ambulate as prescribed. Asking an open-ended question that encourages a discussion about getting out of bed is the best option available to allow the nurse to facilitate the client's plan of care. Pain may be a concern for the client, but again, the nurse is making an unfounded assumption. Although it is true that the recovery might be prolonged by not ambulating and the client may be depressed, these statements make assumptions about the reason the client is refusing to comply with the plan of care.
A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?
- A. Open-ended questions and silence
- B. Offering personal opinions about the need to eat
- C. Verbalizing reasons why the client may choose not to eat
- D. Focusing on self-disclosure of the nurse's own food preferences
Correct Answer: A
Rationale: Open-ended questions and silence are strategies that are used to encourage clients to discuss their feelings in a descriptive manner. Options 2 and 3 are not helpful to the client because they do not encourage the expression of personal feelings. Option 4 is not a client-centered intervention.