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While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.
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A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It facilitates the client's deep breathing
- B. It increases the client's appetite
- C. It promotes wound healing
- D. It decreases the client's anxiety
Correct Answer: A
Rationale: The correct answer is A: It facilitates the client's deep breathing. Postoperative clients following CABG surgery are at risk for developing atelectasis due to decreased lung expansion. Opioid medications can cause respiratory depression, leading to shallow breathing. By facilitating deep breathing, the nurse helps prevent atelectasis and promotes optimal oxygenation, aiding in the client's recovery. Choices B, C, and D are incorrect as they are not directly related to the immediate physiological needs of a postoperative CABG client. Increasing appetite, promoting wound healing, and decreasing anxiety are important aspects of overall recovery but are not as critical as ensuring proper oxygenation and preventing respiratory complications in the immediate postoperative period.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Inspect the mouth for signs of inhalation injuries
- B. Administer pain medication
- C. Place the client on oxygen therapy
- D. Start an intravenous line
Correct Answer: A
Rationale: The correct answer is A: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening and must be assessed immediately in burn patients. Burns to the face and chest increase the risk of inhalation injuries due to the proximity to the airway. Administering pain medication, placing the client on oxygen therapy, and starting an IV line are important interventions but inspecting the mouth for signs of inhalation injuries takes precedence in this situation to ensure the client's airway is not compromised.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is caused by increased fibrinogen levels.
- C. DIC is caused by a reduction in platelet production.
- D. DIC is caused by a decrease in clotting factors.
Correct Answer: A
Rationale: The correct answer is A because DIC is characterized by abnormal coagulation involving fibrinogen. In septic shock, the body's response triggers widespread activation of the coagulation system, leading to the consumption of clotting factors like fibrinogen. This results in the formation of microclots throughout the body, leading to organ dysfunction. Choices B, C, and D are incorrect as DIC is not caused by increased fibrinogen levels, a reduction in platelet production, or a decrease in clotting factors. It is essential for the nurse to emphasize the role of abnormal coagulation involving fibrinogen in DIC to help the client understand the pathology and potential complications associated with septic shock.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
- A. Cyanosis
- B. Agitation
- C. Hypotension
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Agitation. During an asthma attack, hypoxemia can lead to decreased oxygen supply to the brain, causing agitation due to hypoxia. Cyanosis (A) is a bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia. Hypotension (C) is not typically associated with hypoxemia in asthma. Dizziness (D) is more commonly seen in conditions like hyperventilation rather than hypoxemia. In summary, agitation is the most likely manifestation of hypoxemia during an asthma attack due to decreased oxygen supply to the brain.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Encourage the use of an incentive spirometer
- B. Administer oxygen therapy
- C. Provide early ambulation
- D. Monitor for chest pain
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.