A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Elevate extremity

Send the catheter tip for culture.

Assist in inserting a new IV catheter in a site distal to infiltration site.

Suggest irrigating the IV catheter.

Apply a cool compress to the extremity.

Administer phytonadione.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Elevate extremity. Anticipated. This helps to reduce swelling and improve blood flow to the affected area. Send the catheter tip for culture. Anticipated. This helps to identify the possible cause of infection and guide the appropriate antibiotic therapy.

Assist in inserting a new IV catheter in a site distal to infiltration site. Contraindicated. A new IV catheter should be inserted in a site proximal to the infiltration site or in another extremity to avoid further damage to the infiltrated vein.

Suggest irrigating the IV catheter. Contraindicated. Irrigating the IV catheter may worsen the infiltration and increase the risk of complications.

Apply a cool compress to the extremity. Anticipated. This helps to reduce inflammation and pain at the infiltration site.

Administer phytonadione. Contraindicated.Phytonadione is a vitamin K antagonist that is used to reverse the effects of warfarin, an anticoagulant. It has no role in the management of IV infiltration.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale:

"Determine the client's ability to use the call light." - This is the correct answer. Assessing the client's ability to use the call light is the first step in fall prevention. If the client can effectively use the call light, they can request assistance when needed, reducing the risk of falls. It's essential to assess their communication and mobility abilities.

Choice B rationale:

"Create a schedule with an assistive personnel to do hourly rounding for the client." - While hourly rounding is a valuable fall prevention strategy, assessing the client's ability to use the call light should be the initial step to ensure immediate access to help. Rounding can complement this measure.

Choice C rationale:

"Move the bedside table with the client's personal items close to the bed." - While ensuring the client's personal items are within reach is important for their comfort and convenience, it is not the first step in fall prevention. Assessing the client's ability to request assistance takes precedence.

Choice D rationale:

"Apply rubber-soled slippers before ambulation." - Providing appropriate footwear is important for fall prevention, but it is not the first precaution to implement. Assessing the client's ability to use the call light and communicate their needs comes before addressing ambulation.

A. "Let's discuss this when we have more time.” B. "I wouldn't worry about this right now. C. "I can't imagine how difficult it would be to lose my hair.” D. "I will get you information about some head-covering options.” L. t's focus on your chemotherapy.”

Correct Answer is D

Explanation

Choice A rationale:

Delaying the discussion about managing hair loss when the client has expressed concern is not the best approach. The nurse should provide information and support when the client seeks it.

Choice B rationale:

Discouraging the client from worrying about hair loss at this moment is not empathetic. The client's concerns should be acknowledged and addressed.

Choice C rationale:

Expressing empathy and relating to the client's emotional experience is a good practice, but it does not directly answer the client's question about managing hair loss.

Choice D rationale:

Offering to get information about head-covering options indicates an understanding of the client's concerns and provides a proactive solution. It shows empathy and willingness to support the client during chemotherapy, where hair loss can be a significant emotional issue.

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A nurse is assisting with the care of a client who has pneumonia. Exhibits For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls.Which of the following fall precautions should the nurse plan to implement first?

Correct Answer is A

Explanation

A nurse is caring for a client who is to begin chemotherapy.The client asks the nurse about managing hair loss.Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.