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

Exhibits

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

Elevate extremity

Send the catheter tip for culture.

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

Suggest irrigating the IV catheter.

Apply a cool compress to the extremity.

Administer phytonadione.

Answer and Explanation

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

Elevate extremity. Anticipated. This helps to reduce swelling and improve blood flow to the affected area. Send the catheter tip for culture. Anticipated. This helps to identify the possible cause of infection and guide the appropriate antibiotic therapy.

Assist in inserting a new IV catheter in a site distal to infiltration site. Contraindicated. A new IV catheter should be inserted in a site proximal to the infiltration site or in another extremity to avoid further damage to the infiltrated vein.

Suggest irrigating the IV catheter. Contraindicated. Irrigating the IV catheter may worsen the infiltration and increase the risk of complications.

Apply a cool compress to the extremity. Anticipated. This helps to reduce inflammation and pain at the infiltration site.

Administer phytonadione. Contraindicated.Phytonadione is a vitamin K antagonist that is used to reverse the effects of warfarin, an anticoagulant. It has no role in the management of IV infiltration.

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Correct Answer is B

Explanation

Choice A rationale:

Decreased platelets are not typically an indicator of infection. Platelet levels may decrease in conditions like thrombocytopenia, but they are not a specific indicator of infection.

Choice B rationale:

Increased erythrocyte sedimentation rate (ESR) is an indicator of infection. An elevated ESR is a nonspecific marker of inflammation in the body, which can be seen in response to infection, among other conditions.

Choice C rationale:

Decreased hemoglobin is not typically an indicator of infection. Hemoglobin levels may decrease in conditions like anemia, but they are not a specific indicator of infection.

Choice D rationale:

Increased iron levels are not typically an indicator of infection. Iron levels can vary for various reasons, but they are not a direct marker of infection.

A. Dorsal recumbent. B. Supine. C. Left lateral. D. Semi-Fowler's.

Correct Answer is D

Explanation

Following a subtotal thyroidectomy, the nurse should position the client in a way that minimizes strain on the surgical site and promotes respiratory function. The most appropriate position for this client is:

d) Semi-Fowler's.

Semi-Fowler's position, where the head of the bed is elevated at a 30 to 45-degree angle, helps reduce swelling at the surgical site and facilitates breathing. This position also minimizes tension on the suture line and aids in preventing strain on the neck.

The other options are not as suitable for post-thyroidectomy positioning:

a) Dorsal recumbent: This position involves lying on the back with the knees flexed. While it might be used in some situations, it doesn't specifically address the considerations after a thyroidectomy.

b) Supine: Lying flat on the back may not provide optimal support to the neck and could potentially increase discomfort.

c) Left lateral: Lying on the left side may not be as effective in reducing strain on the neck and surgical site compared to the semi-Fowler's position.

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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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

Exhibits

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