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 C

Explanation

A) Assists the client to the bathroom every 2 hr: This action is appropriate as regular assistance with toileting can help prevent falls by ensuring the client is not trying to get up unassisted when they need to use the bathroom. Assisting every 2 hours is reasonable to minimize the risk of falls, especially in clients who are at risk.

B) Clears furniture from the path leading to the bathroom: This action is correct as it reduces environmental hazards that could contribute to a fall. Ensuring that the path to the bathroom is free from obstacles is a key safety measure for clients at risk for falls.

C) Raises all four side-rails on the client's bed: This is an action the nurse should intervene on. Raising all four side rails is considered a restraint in many settings and could increase the risk of injury if the client tries to climb over or becomes entangled. It can also contribute to a feeling of entrapment or confusion. Side rails should only be used according to specific protocols and when necessary for safety, not as a blanket solution for fall prevention.

D) Locks the wheels on the client's bed: Locking the wheels on the bed is an appropriate safety measure. Ensuring the bed is stationary when the client is in it reduces the risk of accidental movement and potential falls.

A. Yellowing of the eyes B. Blurred vision C. Dry eyes D. Abdominal pain E. Weight gain F. Increased bruising G. Increased bleeding tendancies H. Insomnia I. Darkening of the urine J. Urinary frequency

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

Explanation

Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.

Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.

Dry eyes (Incorrect) → Not a common side effect of TB medications.

Gastrointestinal:

Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.

Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.

Hematologic:

Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.

Insomnia (Incorrect) → Not a serious adverse effect of TB medications.

Genitourinary:

Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.

Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.

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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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 supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is C

Explanation

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

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.