The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. Which action should the charge nurse take?

Plan to observe the secured IV site after the insertion procedure.

Remind the nurse to tape the gauze dressing securely in place.

Confirm that the nurse has gathered the necessary supplies.

Instruct the nurse to use a transparent dressing over the site.

Answer and Explanation

The Correct Answer is D

A. Plan to observe the secured IV site after the insertion procedure.
This is a proactive step, but it does not address the immediate need to correct the new nurse’s choice of dressing.

B. Remind the nurse to tape the gauze dressing securely in place.
While securing the dressing is important, it is not the best practice to use a gauze dressing for IV sites as it obscures the view of the insertion site.

C. Confirm that the nurse has gathered the necessary supplies.
Confirming supplies is important, but this does not address the incorrect dressing choice.

D. Instruct the nurse to use a transparent dressing over the site.
This is the correct answer because a transparent dressing allows for continuous visual inspection of the IV site for signs of infection or infiltration, which is crucial for patient safety.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Actions to Take:

A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic

autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its

progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes.

B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity.

Potential Condition:

D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment.

Parameters to Monitor:

C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies.

D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.

A. Shaking is lessened B. Client is no longer flushed C. No longer itching D. Anxiety has decreased E. Skin warm and dry F. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg G. No chest pain noted H. Respirations are even and unlabored I. Drowsy

Correct Answer is ["A","B","C","D","E","F","G","H","I"]

Explanation

Shaking is lessened: Shaking or tremors can be a manifestation of the body's response to stress or discomfort. A decrease in shaking suggests that the client's physiological response is returning to normal, indicating improvement.
Client is no longer flushed: Flushing, or the reddening of the skin, can occur as a result of vasodilation during an allergic reaction or due to increased blood flow associated with elevated body temperature. The absence of flushing suggests that the body's inflammatory response has subsided, indicating resolution of the adverse reaction.
No longer itching: Itching, or pruritus, is a common symptom of allergic reactions mediated by histamine release. The cessation of itching suggests that the inflammatory mediators responsible for the itching response have been cleared from the body, indicating resolution of the allergic reaction.
Anxiety has decreased: Anxiety can be a psychological response to physical discomfort or distress. A decrease in anxiety levels suggests that the client is experiencing less discomfort and is psychologically improving, which can be indicative of recovery from the adverse drug reaction.
Skin warm and dry: Warm and dry skin is a sign of normal thermoregulation and hydration status. The presence of warm and dry skin suggests that the client's body temperature andhydration levels are within normal limits, indicating physiological stability and recovery from the adverse drug reaction.
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: Vital signs within normal limits, including a heart rate and blood pressure within the client's baseline range, indicate stability of cardiovascular function and resolution of any hemodynamic instability associated with the adverse drug reaction.
No chest pain noted: Chest pain can be indicative of cardiovascular compromise or ischemia. The absence of chest pain suggests that the client's cardiovascular function has normalized, further supporting recovery from the adverse drug reaction.
Respirations are even and unlabored: Even and unlabored respirations indicate normal respiratory function and adequate gas exchange. The absence of respiratory distress or effort suggests resolution of any respiratory complications associated with the adverse drug reaction.
Drowsy: Drowsiness can be a side effect of medications such as antihistamines or a natural response to the body's recovery process. While drowsiness may persist for a period after the adverse drug reaction resolves, its presence alongside other signs of improvement suggests that the client's body is returning to a state of equilibrium.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Correct Answer is ["A","B","C","D","E","F","G","H","I"]

Explanation

Exhibits The nurse reviews the findings in the history and physical. Select from Word Choices to complete the sentence. The nurse recognizes that dropdown ,dropdown and dropdown are findings consistent with elder mistreatment.

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. For the primary survey, what 2 things should the nurse do first?

An intravenous (IV) antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. Which schedule is best for administering this prescription?

Exhibits here Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?