Nokea
Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.
You may also like to solve these questions
The best diet for the client with Meniere's syndrome is one that is:
- A. High in fiber
- B. Low in sodium
- C. High in iodine
- D. Low in fiber
Correct Answer: B
Rationale: A low-sodium diet is best for Meniere's syndrome, reducing fluid retention in the inner ear, which mitigates vertigo, tinnitus, and hearing loss flare-ups. High fiber aids digestion, not ear issues; high iodine or low fiber lacks relevance here. Nurses teach this dietary shift to control symptoms, emphasizing sodium's role in fluid balance, supporting long-term management of this chronic condition.
Which one of the following four clients is most likely to tolerate pain best?
- A. a client with rheumatoid arthritis
- B. a client who has terminal cancer in stage 1 of grief
- C. an athlete having a knee surgery to prolong his career
- D. a client who has a migraine headache
Correct Answer: C
Rationale: An athlete undergoing knee surgery likely tolerates pain best, motivated by career goals, unlike chronic arthritis, cancer grief, or migraines. Nurses consider this in pain management.
The nurse is preparing to take vital signs in an alert client admitted with dehydration secondary to vomiting and diarrhea. What is the best method to assess the client's temperature?
- A. Oral
- B. Axillary
- C. Radial
- D. Heat sensitive tape
Correct Answer: B
Rationale: Axillary is safest and most accessible for a dehydrated client with GI issues, avoiding oral route due to vomiting and diarrhea.
Which of the following statement is NOT true about complementary therapy?
- A. Used with conventional medicine
- B. Includes acupuncture
- C. Always replaces medical treatment
- D. May improve well-being
Correct Answer: C
Rationale: Complementary therapy pairs with medicine (A), includes acupuncture (B), may improve well-being (D) 'always replaces' (C) isn't true, it's adjunctive, per definition. C's replacement fails, making it untrue.
As a nurse manager, which of the following best describes this function?
- A. Initiate modification on client's lifestyle
- B. Protect client's right
- C. Coordinates the activities of other members of the health team in managing patient care
- D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
Correct Answer: D
Rationale: A nurse manager's role encompasses planning (vision formulation), organizing (team coordination), directing (training), and controlling (audits), per management theories like Venzon's. This holistic function e.g., setting care standards, training staff, evaluating outcomes ensures quality across a unit, unlike narrower roles like lifestyle change (change agent), rights protection (advocate), or team coordination (case manager). It's a strategic position driving institutional excellence, pivotal in healthcare leadership.