Nokea
The nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which action should the nurse take to determine if the IV has infiltrated?
- A. Strip the tubing and assess for a blood return.
- B. Check the regional tissue for redness and warmth.
- C. Increase the infusion rate and observe for swelling.
- D. Gently palpate regional tissue for edema and coolness.
Correct Answer: D
Rationale: When assessing an IV for clinical indicators of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the surrounding tissues, which can increase the risk of tissue damage. Redness and warmth are more likely to indicate infection or phlebitis.
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A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication?
- A. Infuse over 1 hour and allow the client to ambulate.
- B. Infuse over 1 hour with the client in a supine position.
- C. Administer over 30 minutes with the client in a reclining position.
- D. Administer by IV push over 15 minutes with the client in a supine position.
Correct Answer: B
Rationale: IV pentamidine is an antifungal medication infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias. Options 1, 3, and 4 are inaccurate in either the length of time that pentamidine is administered or the client's position.
The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours. Which result should indicate to the nurse that the client is experiencing an adverse effect of the medication?
- A. A total bilirubin of 0.5 mg/dL (8.5 mcmol/L)
- B. An erythrocyte sedimentation rate of 15 mm/hour
- C. A blood urea nitrogen (BUN) of 30 mg/dL (10.8 mmol/L)
- D. A white blood cell count (WBC) of 6000 mm³ (6 × 10â¹/L)
Correct Answer: C
Rationale: Tobramycin sulfate is an aminoglycoside antibiotic. Adverse effects or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. The normal BUN ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L), depending on the laboratory. The normal total bilirubin level ranges from 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate for a male is ≤15 mm/hr and for a female is ≤20 mm/hr. A normal WBC count is 5000 to 10,000 mm³ (5 to 10 × 10â¹/L).
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action?
- A. Breathes in and then holds the breath for 30 seconds
- B. Loosens the abdominal muscles while breathing out
- C. Inhales with puckered lips and exhales with the mouth open wide
- D. Breathes so that expiration is two to three times as long as inspiration
Correct Answer: D
Rationale: COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing.
The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes securely in place?
- A. Secure the electrodes with adhesive tape.
- B. Place clear, transparent dressings over the electrodes.
- C. Apply lanolin to the skin before applying the electrodes.
- D. Cleanse the skin with alcohol before applying the electrodes.
Correct Answer: D
Rationale: Alcohol defats the skin and helps the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode make better contact with the diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence.
A client, admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia, is scheduled for electrophysiology studies (EPS). Which statement should the nurse include in a teaching plan for this client?
- A. You will continue to take your medications until the morning of the test.
- B. You will be sedated during the procedure and will not remember what has happened.
- C. This test is a noninvasive method of determining the effectiveness of your medication regimen.
- D. The test uses a special wire to increase the heart rate and produce the irregular beats that cause your signs and symptoms.
Correct Answer: D
Rationale: The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test to study the dysrhythmias without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.