Nokea
The nurse is assessing a client receiving intravenous (IV) fluids via a peripheral vascular access device (PVAD). Assessment findings show swelling and tenderness at the infusion site. The nurse should perform which action?
- A. stop the infusion and remove the PVAD
- B. remove the dressing and reposition the PVAD
- C. instruct the client to perform range of motion activities in the affected arm
- D. place the arm in a dependent position
Correct Answer: A
Rationale: Swelling and tenderness indicate infiltration, requiring stopping the infusion and removing the PVAD.
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A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
- A. Contact the client's audiologist.
- B. Cleanse the hearing aid ear mold in normal saline.
- C. Irrigate the ear canal.
- D. Check the hearing aid's placement.
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage?
- A. Numbness.
- B. Bleeding.
- C. Dislocation.
- D. Pinkness.
Correct Answer: A
Rationale: Numbness indicates potential nerve damage, requiring urgent evaluation.
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?
- A. Antibiotics will need to be taken for 1 to 2 weeks.
- B. Arm exercises will get rid of the cellulitis.
- C. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling.
- D. The right extremity should be lowered to improve blood flow to the forearm.
Correct Answer: A
Rationale: Antibiotics for 1-2 weeks are the primary treatment for cellulitis, a bacterial infection, to prevent complications in a post-mastectomy client with lymphedema risk.