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The nurse is caring for a client who is receiving an intravenous infusion. Which finding would indicate that the client's IV has infiltrated?
- A. The client's arm is red and warm to the touch.
- B. The IV is running faster than the desired rate.
- C. The area around the infusion site is pale and cool to the touch.
- D. The client complains of severe pain up and down the arm.
Correct Answer: C
Rationale: Infiltration causes pale, cool skin around the IV site due to fluid leakage into tissues. Redness, fast infusion, or radiating pain suggest other issues.
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The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?
- A. I have gained so much weight in the last few months.
- B. I am having trouble getting an erection.
- C. My legs are cramping and I feel like I need to walk all the time.
- D. It's really embarrassing. I'm drooling a lot.
Correct Answer: C
Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.
The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for
- A. dietary sodium restriction
- B. magnesium hydroxide
- C. fluid restriction
- D. furosemide
Correct Answer: B
Rationale: Magnesium hydroxide risks toxicity in CKD due to impaired excretion. Sodium restriction , fluid restriction , and furosemide are appropriate.
The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?
- A. Bend at the waist
- B. Keep the feet close together
- C. Pivot on the foot proximal to the chair
- D. Use a transfer belt
Correct Answer: D
Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.
The nurse is caring for a client who has a prescription for furosemide 1 mg/kg PO every 8 hours. The client weighs 44 lb (20 kg). The nurse has furosemide oral solution 10 mg/mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: Dose: 1 mg/kg × 20 kg = 20 mg. Solution: 20 mg ÷ 10 mg/mL = 2 mL .
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
- A. Alteration in comfort
- B. Alteration in mobility
- C. Alteration in skin integrity
- D. Alteration in O2 perfusion
Correct Answer: B
Rationale: Alteration in mobility is priority for a detached retina, as positioning and activity restrictions prevent further detachment. Comfort, skin integrity, and O2 perfusion are secondary concerns.