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 D

Explanation

Choice A rationale:

Hegar's sign is a softening of the uterine isthmus, which occurs during early pregnancy. It is not related to changes in the color of the vagina and vulva.

Choice B rationale:

Chloasma refers to the appearance of dark, blotchy, and hyperpigmented skin patches that can occur during pregnancy, primarily on the face. It is not related to changes in the color of the vagina and vulva.

Choice C rationale:

Ballottement is a technique used during a physical examination to assess for a floating fetus within the amniotic fluid. It is not related to changes in the color of the vagina and vulva.

Choice D rationale:

Chadwick's sign is the purplish or bluish discoloration of the vaginal and vulvar mucosa that can occur during pregnancy. This sign is due to increased blood flow to the area, which is a normal physiological change in pregnancy.

A. Hospice care. B. Adult day care facility. C. Community senior center. D. Long-term care facility.

Correct Answer is B

Explanation

Choice A rationale:

Hospice care is typically recommended for clients with a terminal illness who are no longer seeking curative treatment. It may not be suitable for an older adult with early onset dementia unless their condition is very advanced.

Choice B rationale:

Recommending an adult day care facility is appropriate in this situation. Adult day care centers provide a safe and stimulating environment for older adults who require supervision and socialization during the day. It can be a helpful resource for the client's care while the adult child is at work.

Choice C rationale:

Suggesting a community senior center is a good option for social engagement and activities, but it may not provide the level of supervision and care needed for an older adult with dementia, especially if the adult child works full-time.

Choice D rationale:

Recommending a long-term care facility is a more drastic step and is typically considered when a client's care needs cannot be met at home or in less restrictive settings. It may not be necessary for a client with early onset dementia who still has family support.

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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

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.The nurse notes that the client's vagina and vulva are a purplish color.The nurse should document this finding as which of the following?

Correct Answer is D

Explanation

A nurse is assisting with the discharge of an older adult client who has early onset dementia and lives with their adult child who works full time.Which of the following resources should the nurse recommend to the family to assist with the client's care?

Correct Answer is B

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.