A nurse is caring for a client who is receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take?

Aspirate fluid from the IV cannula.

Place the affected extremity below the level of the client's heart.

Slow the IV infusion.

Place a pressure dressing over the IV site.

Answer and Explanation

The Correct Answer is C

Choice A reason: Aspirating fluid from the IV cannula is not recommended as it does not address the issue of infiltration or extravasation.

Choice B reason: Placing the affected extremity below the level of the client's heart could worsen the swelling and is
not recommended.

Choice C reason: Slowing the IV infusion is a correct immediate action to minimize further infiltration and should be done while further assessment and interventions are planned.

Choice D reason: Placing a pressure dressing over the IV site is not recommended as it may exacerbate the infiltration
and increase discomfort.

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Correct Answer is B

Explanation

Choice A reason: Alternating liquids and solids is not a specific intervention for dysphagia management.

Choice B reason: Elevating the head of the bed to 45 degrees or higher during meals can help prevent aspiration in
clients with dysphagia.

Choice C reason: Telling a client with dysphagia to tilt their head back while swallowing can increase the risk of aspiration.

Choice D reason: Turning on the television is not a recommended practice as it can distract the client from focusing
on safe swallowing techniques.

A. Memory loss B. Bleeding gums C. Brittle hair D. Constipation

Correct Answer is D

Explanation

Choice A reason: Memory loss is not typically associated with a lack of dietary fiber. Memory loss can be related to various neurological or psychological conditions.

Choice B reason: Bleeding gums are commonly associated with vitamin C deficiency, not a lack of dietary fiber.

Choice C reason: Brittle hair can be associated with poor nutrition in general, but it is not a specific indicator of inadequate fiber intake.

Choice D reason: Constipation is a well-known symptom of inadequate fiber intake. Fiber helps to bulk up the stool
and promotes regular bowel movements.

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A nurse is caring for a client who is receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is collecting data on a client who has Chronic Obstructive Pulmonary Disease (COPD). Which of the following findings should the nurse expect? A. Pleural friction rub B. Peripheral edema C. Spoon nails D. Hyperresonance on percussion

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