A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.
On Day 1, Lactated Ringer’s was infusing at 100 mL/hr into a 20-gauge IV catheter in the left hand. The IV dressing was dry and intact.
The IV site was without redness or swelling. The IV fluid was infusing well.
On Day 2, the IV site was edematous.
The skin surrounding the catheter site was taut, blanched, and cool to touch. The IV fluid was not infusing.
The nurse is assessing the client.
Which of the following actions should the nurse take?

Stop the IV infusion.

Elevate the client’s left arm.

Apply heat to the client’s left hand.

Start a new IV in the client’s left hand.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.

Choice B rationale

The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.

Choice C rationale

The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.

Choice D rationale

Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.

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Correct Answer is B

Explanation

Choice A rationale

While colonoscopy is a screening method for colon cancer, it is not typically recommended to begin at age 60 for individuals at average risk. Instead, colonoscopy screening is usually recommended to begin at age 50 and continue every 10 years if no polyps are found.

Choice B rationale

The recommendation for an average risk individual for colon cancer is to have a fecal occult blood test every year. This test checks for hidden blood in the stool, which can be an early sign of cancer.

Choice C rationale

Sigmoidoscopy every 10 years is another screening option for colon cancer. However, it only examines the rectum and lower third of the colon, whereas a colonoscopy examines the entire colon.

Choice D rationale

Blood tests are not typically used as a primary screening method for colon cancer. They may be used in conjunction with other tests, but a blood sample alone is not sufficient for screening.

A. “We would give you oxygen through a tube in your nose.”. B. “You would be unable to change your previous wishes about your care.”. C. “We would insert a breathing tube while we evaluate your condition.”. D. “We would consult the person appointed by your health care proxy to make decisions.”. .

Correct Answer is A

Explanation

Choice A rationale

If a patient with a living will arrived at the emergency department with difficulty breathing, the healthcare team would provide immediate care to ease the patient’s distress, such as administering oxygen.

Choice B rationale

While a living will outlines a patient’s wishes for end-of-life care, it does not prevent the patient from receiving immediate, necessary care in an emergency situation.

Choice C rationale

Inserting a breathing tube may be necessary in some cases, but it would not be the first step in managing difficulty breathing.

Choice D rationale

While the healthcare team would consult the person appointed by the patient’s healthcare proxy to make decisions, immediate care would not be delayed.

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a middle-aged patient who states, “The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening.What does that involve?” Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is educating a terminally ill patient about declining resuscitation in a living will.The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is providing care for a patient who has terminal liver cancer.Which statement from the patient should the nurse recognize as a sign of spiritual distress?

A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?

A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

A nurse is administering an otic medication to an older adult patient.Which of the following actions should the nurse take to ensure the medication reaches the inner ear?

A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?