Nokea
The nurse is caring for a client receiving a continuous infusion of isotonic fluids and observes infiltration at the vascular access device. The nurse should take which action?
- A. Reduce the infusion rate and elevate the affected extremity.
- B. Stop the infusion and remove the intravenous (IV) catheter.
- C. Stop the infusion and reposition the intravenous (IV) catheter into the vein.
- D. Reduce the infusion rate and apply a warm compress to the intravenous (IV) site.
Correct Answer: B
Rationale: Infiltration requires stopping the infusion and removing the catheter to prevent further tissue damage.
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Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
The nurse is teaching a client how to manage a nosebleed. Which of the following instructions would be appropriate to give the client?
- A. Tilt your head backward and pinch your nose.
- B. Lie down flat and place an ice compress over the bridge of the nose.
- C. Blow your nose gently with your neck
- D. Sit down, lean forward, and pinch the soft portion of your nose.
Correct Answer: D
Rationale: Sitting and leaning forward while pinching the soft portion of the nose compresses the bleeding site and prevents blood from flowing down the throat. Tilting backward can cause swallowing of blood. Lying flat is not recommended. Blowing the nose can worsen bleeding.
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
- A. Sudden, sharp chest pain.
- B. Wheezing breath sounds over affected side.
- C. Hemoptysis.
- D. Cyanosis.
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.
The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision?
- A. Adjust the physician's order based on the client's pain level
- B. Ensure naloxone is always available
- C. Check the client's blood pressure before administering morphine sulfate
- D. Provide a high-fiber diet
Correct Answer: A
Rationale: Nurses cannot adjust physician orders independently; this requires clarification or a new order from the provider.
Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease?
- A. 45-year-old mother.
- B. 17-year-old daughter.
- C. 8-year-old son.
- D. 76-year-old grandmother.
Correct Answer: D
Rationale: The elderly (76-year-old grandmother) are at highest risk due to weakened immune systems, increasing susceptibility to tuberculosis infection. Children and younger adults are less vulnerable unless immunocompromised.