Nokea
The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
- A. The client says the IV fluid feels cool when it goes in.
- B. The infusion site is covered with clear tape.
- C. The client is ambulating while the IV infusion is running.
- D. The area around the infusion site is cool and blanched.
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.
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The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following laboratory results should the nurse report immediately?
- A. Blood glucose of 200 mg/dL.
- B. Potassium 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (3.0 mEq/L) risks arrhythmias during insulin therapy for DKA. Options A, C, and D are less urgent.
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.
The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 88 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Absence of bowel sounds.
- D. Pain rated as 6 out of 10.
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.