Nokea
The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?
- A. Occlusion
- B. Infiltration
- C. Phlebitis
- D. Air embolism
Correct Answer: C
Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.
You may also like to solve these questions
The nurse is interviewing an older adult who reports a disturbed sleep pattern. The client states that he lies in bed tossing and turning and cannot fall asleep. The nurse should recommend that the client
- A. Stay in bed until he falls asleep but change positions more frequently.
- B. Take more naps earlier in the day that do not exceed one hour.
- C. Eat a meal high in carbohydrates to promote sleep.
- D. Reduce your time in bed if unable to fall asleep after 20 minutes.
Correct Answer: D
Rationale: Leaving bed after 20 minutes prevents associating bed with sleeplessness, a sleep hygiene principle. Staying in bed, napping, or high-carb meals disrupt sleep patterns.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Immediately evacuate clients and personnel from the area.
- B. Don personal protective equipment (PPE) before cleaning up the spill.
- C. Contain the spill using non-absorbable sheets or pads.
- D. Complete an incident report.
- E. Discard all material used in cleanup in a trash bag.
- F. Implement droplet precautions after the spill has been cleaned.
Correct Answer: A,B,C,D
Rationale: Evacuation, PPE, containment, and incident reporting are standard for chemotherapy spills. Cleanup materials require biohazard disposal, not regular trash.
The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test?
- A. Urine specific gravity
- B. Liver function tests
- C. Blood glucose
- D. Creatine kinase
Correct Answer: C
Rationale: PET scans often use glucose-based tracers, so blood glucose levels must be checked to ensure accurate imaging. Other labs are not routinely required.
The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life?
- A. Advocate for pain management unless life-threatening side effects occur.
- B. Advocate for pain management even if the life-threatening side effects hasten death.
- C. Prohibit the respiratory system from depressing drugs because this is euthanasia.
- D. Allow families to administer respiratory system depressing drugs to hasten death.
Correct Answer: B
Rationale: The ANA supports pain relief at end-of-life, even if side effects like respiratory depression hasten death, prioritizing comfort. Other options misalign with ethical standards.
The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.