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Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client’s pulse rate every hour
Correct Answer: B
Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.
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A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
- A. Impaired physical mobility
- B. Disturbed body image
- C. Risk for infection
- D. Risk for social isolation
Correct Answer: B
Rationale: The correct answer is B: Disturbed body image. The client expressing concern about the external fixation device making his leg look ugly indicates a disturbance in how he perceives his body image. This can lead to feelings of low self-esteem and impact his overall psychological well-being. Impaired physical mobility (A) is not the priority as the concern is not related to limitations in movement. Risk for infection (C) may be a potential risk with the device but is not directly related to the client's current concern. Risk for social isolation (D) is not directly indicated by the client's statement about the appearance of the leg. Therefore, the most appropriate nursing diagnosis is Disturbed body image (B) based on the client's expressed concern.
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature.
Rationale:
1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet.
2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet.
3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet.
Summary:
Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.
for pain management. When applying a new system, the nurse should:
- A. Press the system in place for 30 to 60 seconds.
- B. Choose a site on the lower torso.
- C. Shave the application site before use.
- D. Apply the system immediately after removal from a package.
Correct Answer: A
Rationale: Rationale:
A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system.
B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference.
C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system.
D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors
- A. Positive ELISA and Western blot tests
- B. Evidence of extreme weight loss and high fever
- C. Identification of an associated opportunistic infection
Correct Answer: A
Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.