A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

Establish a second IV site.

Stop the normal saline infusion.

Assess the IV for blood return. D. Discontinue the 24 gauge IV.

Discontinue the 24 gauge IV.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B)   Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C)   Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D)   Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.

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Correct Answer is ["B","D","E"]

Explanation

A. Keeping the battery door closed during storage is generally a good practice to prevent battery drain; however, it may be more appropriate to keep it open for extended storage to avoid moisture buildup. The PN should clarify proper storage practices.
B. Observing and reporting any ear drainage after removing the device is crucial. Any drainage could indicate an infection or other issues that require further evaluation by nursing staff.
C. Storing the device on a windowsill is not advisable, as this increases the risk of loss or damage. A secure, designated storage area is better for such items.
D. Verifying that the device is labeled with the client's identification is important to prevent mix-ups and ensure proper usage. Proper labeling aids in maintaining accountability and safety in a long-term care setting.
E. Removing ear wax from the device's surface is appropriate as it ensures the hearing aid functions properly and maintains hygiene.

A. Skipped eating lunch. B. Incorrectly administered too much insulin. C. Had a cold and ear infection for the past two days. D. Ate an extra peanut butter sandwich before gym class. E. None F. None

Correct Answer is C

Explanation

A. Skipped eating lunch would more likely cause hypoglycemia rather than diabetic ketoacidosis (DKA). When a person with type 1 diabetes skips a meal but still takes insulin, blood glucose levels drop, leading to hypoglycemia, not the elevated glucose and ketone production seen in DKA.

B. Incorrectly administered too much insulin would also result in hypoglycemia rather than DKA. Administering excessive insulin causes blood glucose levels to fall too low, which does not trigger the fat breakdown and ketone production that characterize DKA.

C. Had a cold and ear infection for the past two days is the most likely cause of diabetic ketoacidosis. Illness and infection cause the body to release stress hormones such as cortisol and adrenaline, which increase blood glucose levels and counteract insulin. In type 1 diabetes, insufficient insulin leads to hyperglycemia, fat breakdown for energy, and the production of ketones, resulting in DKA.

D. Ate an extra peanut butter sandwich before gym class would not cause DKA. Consuming extra food may raise blood glucose temporarily, but it would not lead to the severe insulin deficiency and ketone production seen in DKA, especially if the adolescent took insulin as prescribed.

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A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

Correct Answer is C

Explanation

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