Nokea
A client who has clear lung sounds and unlabored breathing is receiving aminophylline IV.
Which of the following would be the MOST appropriate nursing action if the client's IV infiltrates?
- A. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.
- B. Wait two hours, reassess the client, and restart the IV if the client has wheezing or labored breathing.
- C. Restart the IV and continue the previous medication schedule.
- D. Call the physician and recommend that the IV medications be changed to PO.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) continued IV medication may not be necessary based on the current assessment (2) physician should be notified if IV medications are not infusing as scheduled (3) client has improved breathing, so IV medications may not be indicated (4) correct-before a new IV is started on this client, physician should be called and PO medications recommended
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A client has a chest tube inserted for treatment of a hemothorax.
Which of the following findings would indicate to the nurse that there is a problem with the effective functioning of the chest tube?
- A. 15-cm of water is present in the suction control chamber.
- B. Constant bubbling is observed in the water seal chamber.
- C. 2-cm of water is present in the water seal chamber.
- D. Clots of blood are observed in the collection chamber.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) appropriate, regulates the amount of suction delivered to the patient (2) correct-would indicate an air leak, would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present, to collect information
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct Answer: C
Rationale: Consult the human resources department about the issue and needed actions. To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources.
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
- A. 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
- B. 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
- C. 3 days post partum, temperature of 101.2 degrees Fahrenheit the past 2 days
- D. 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Correct Answer: C
Rationale: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.