Nokea
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.
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A client with AIDS shows symptoms of herpes simplex stomatitis. Which drug therapy can be anticipated for the client?
- A. Lypressin (Vasopressin)
- B. Liothyroxine (Triostat)
- C. Acyclovir (Zovirax)
- D. Dexamethasone (Maxidex)
Correct Answer: C
Rationale: Acyclovir is an antiviral drug used to treat herpes simplex infections, including stomatitis in AIDS patients.
A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct Answer: D
Rationale: Discontinue a new food that was added to the infant's diet just prior to the rash. New foods can be a cause of diaper dermatitis.
Laboratory reference ranges
Hematocrit
39%-59%
(0.39-0.59)
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.
Which one of the following symptoms is commonly reported in children with attention deficit hyperactive disorder?
- A. Difficulty sleeping at night
- B. Impulsivity
- C. Poor appetite
- D. Nonintentional tremor
Correct Answer: B
Rationale: Impulsivity is a hallmark symptom of ADHD, characterized by acting without forethought, often seen in children with the disorder.
The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO after midnight
- B. Client should receive a sedative medication prior to the test
- C. Discontinue anti-coagulant therapy prior to the test
- D. No special preparation is necessary
Correct Answer: D
Rationale: This is a non-invasive procedure and does not require preparation other than client education.