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Why is it most important to start intravenous infusions in the upper extremities rather than the lower extremities of adults?
- A. Superficial veins are more easily found in the feet and ankles.
- B. A decreased flow rate could lead to thrombosis formation.
- C. It is more challenging to move a cannulated extremity when using the leg or foot.
- D. Veins in the feet and ankles are located deep, making the procedure more painful.
Correct Answer: B
Rationale: The most critical reason for initiating intravenous infusions in the upper extremities of adults is to reduce the risk of thrombosis (B). Venous return is typically better in the upper extremities, decreasing the likelihood of thrombus formation, which could be life-threatening if dislodged. Although superficial veins are easily found in the feet and ankles (A), this is not the primary reason for choosing the upper extremities. Handling a leg or foot with an IV (C) is not significantly more challenging than handling an arm or hand. The depth of veins in the feet and ankles (D) does not primarily determine the site for IV placement.
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When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?
- A. Position the client supine for a few minutes
- B. Assist the client to stand at the bedside
- C. Apply the blood pressure cuff securely
- D. Record the client's pulse rate and rhythm
Correct Answer: A
Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
- A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
- B. Notify the healthcare provider and request a prescription for a large-volume enema.
- C. Assess the client's medical record to determine the client's normal bowel pattern.
- D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
Correct Answer: C
Rationale: When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
- A. Give analgesics on an around-the-clock schedule for pain management.
- B. Administer analgesic medication only when the pain becomes severe.
- C. Provide medication to keep the client comfortable without inducing sedation.
- D. Allow brief medication-free periods to promote comfort during daily activities.
Correct Answer: A
Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (A) to maintain pain control. Waiting until pain is severe before administering medication (B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized. Therefore, keeping the client comfortable without excessive sedation (C) is preferred. Allowing for some periods without medication (D) may be appropriate but should not compromise the client's comfort and pain control.
The healthcare professional observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the healthcare professional's intervention?
- A. The cuff wraps around the girth of the leg.
- B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
- C. The client is placed in a prone position.
- D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct Answer: B
Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. Auscultating the popliteal pulse with the cuff on the lower leg is incorrect as it may lead to an inaccurate reading. Placing the client in a prone position and wrapping the cuff around the girth of the leg are acceptable practices. A systolic reading that is 20 mm Hg higher in the lower extremity compared to the arm is expected due to the difference in blood pressure between the upper and lower parts of the body.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?
- A. How will this affect your present sexual activity?
- B. How active is your current sex life?
- C. How has your sex life changed as you have become older?
- D. Tell me about your sexual needs as an older adult.
Correct Answer: A
Rationale: Option A is the best response as it directly addresses the client's concern about the reduction in sexual drive caused by the medication. It encourages the client to express their thoughts and feelings about how this side effect may impact their current sexual activity, facilitating open communication and understanding between the nurse and the client. Choices B, C, and D are not as appropriate as they do not directly address the client's immediate concern regarding the impact of the medication on their sexual drive.