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

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

Administer phytonadione.

Apply cool compress to the extremity.

Elevate extremity.

Suggest irrigating the IV catheter

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

Send the catheter tip for culture.

Answer and Explanation

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

Administer phytonadione (Vitamin K): Contraindicated

There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.

Apply cool compress to the extremity: Anticipated

A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.

Elevate extremity: Anticipated

Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.

Suggest irrigating the IV catheter: Contraindicated

Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.

Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated

A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.

Send the catheter tip for culture: Anticipated

Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.

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Correct Answer is B

Explanation

A) Increase in concentration: Chlorpromazine is an antipsychotic medication used to manage symptoms of schizophrenia and other psychotic disorders. While it may have some effects on cognition, an increase in concentration is not the primary therapeutic effect of chlorpromazine.

B) Decrease in delusions: Chlorpromazine is effective in reducing symptoms of psychosis, such as delusions and hallucinations, which are common in conditions like schizophrenia. A decrease in delusions is a direct indicator that the medication is having its intended therapeutic effect.

C) Increase in alertness: Chlorpromazine can cause sedation and drowsiness as side effects, particularly during the initial stages of treatment. An increase in alertness would not be a typical therapeutic outcome, and it may even suggest a side effect like overstimulation or anxiety rather than the intended effect.

D) Decrease in anxiety: While chlorpromazine may have some calming effects, it is primarily used to treat symptoms of psychosis, not anxiety disorders. A decrease in anxiety is not the main therapeutic effect of chlorpromazine. Other medications, such as benzodiazepines, are typically used for anxiety management.

Correct Answer is ["0.25"]

Explanation

Identify the desired dose:

The doctor has ordered 0.5 mg of haloperidol.

Identify the available medication concentration:

The available haloperidol oral concentrate is 2 mg/mL.

Set up the calculation:

We need to find out how many mL are needed to administer 0.5 mg of the medication. We can use the following formula:

(Desired dose) / (Concentration) = Volume to administer

Plug in the values and calculate:

(0.5 mg) / (2 mg/mL) = 0.25 mL

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A nurse is assisting with the care of a client who has pneumonia. 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 in the care of a client who is taking chlorpromazine. Which of the following findings indicates a therapeutic effect medication?

Correct Answer is B

Explanation

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.25"]

Explanation

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

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