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.

Apply a cool compress to the extremity.

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

Elevate extremity.

Administer phytonadione.

Send the catheter tip for culture.

Suggest irrigating the IV catheter.

Answer and Explanation

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

Anticipated:

Apply a cool compress to the extremity. A cool compress can reduce swelling, relieve discomfort, and help minimize the tightness in the skin caused by edema. The cold temperature helps constrict blood vessels, reducing fluid buildup in the tissues. This intervention is appropriate for managing IV infiltration-related symptoms.
Assist in inserting a new IV catheter in a site distal to the infiltration site. If the IV site becomes infiltrated, the correct approach is to stop the current infusion and insert a new catheter in a different location, preferably distal to the infiltration site. This ensures continued IV access without further aggravating the infiltrated site.
Elevate extremity. Elevating the affected extremity can help reduce swelling by promoting venous return. Elevation improves circulation and decreases the pressure caused by fluid accumulation in the tissues. This is an effective intervention for managing swelling in the right upper extremity due to infiltration.

Not Anticipated:

Phytonadione (vitamin K) is typically used to reverse the effects of anticoagulation medications or treat vitamin K deficiency. This is not indicated for the client, as there is no evidence of bleeding or an anticoagulation issue that requires vitamin K. The client's current problem is an IV infiltration, not a clotting disorder.
Send the catheter tip for culture. At this point, there are no signs of infection such as redness, warmth, or discharge from the IV site. The primary concern is managing the infiltration, so sending the catheter tip for culture is unnecessary unless infection is suspected. Culture collection is reserved for cases where an infection is present.
Suggest irrigating the IV catheter. Irrigating an infiltrated IV catheter could worsen the situation by pushing fluids further into the surrounding tissue or introducing bacteria. The proper action is to discontinue the infusion, remove the IV, and insert a new catheter at a different site rather than attempting to irrigate an already compromised catheter.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "The website was last updated 3 years ago." Medical information evolves rapidly, and outdated sources may contain inaccurate or obsolete data. Regular updates improve credibility.
B. "The author cites references to statements made." Citing references supports the accuracy and credibility of medical information. Reliable sources should provide evidence-based content backed by research or reputable organizations.
C. "The website URL is listed as .com." Commercial websites (.com) can contain valid information, but they may also prioritize marketing over accuracy. Government (.gov), educational (.edu), and nonprofit (.org) sites tend to be more reliable.
D. "The author's name is listed without credentials." Without credentials, it is difficult to verify the author's expertise. Reliable medical sources should have content written or reviewed by professionals with relevant qualifications.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Options:

Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

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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

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Correct Answer is B

Explanation

Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

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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.