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.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask the facility chaplain to visit the client. While spiritual support can be beneficial, the nurse should first acknowledge and respect the client’s decision. Offering a chaplain visit without the client's request may not align with their personal beliefs or needs.
B. Discuss alternative treatment methods with the client. End-stage kidney disease has limited treatment options beyond dialysis or kidney transplantation. If the client has already decided to stop dialysis, discussing alternatives may not be appropriate unless the client expresses interest. The priority is to support their decision and provide comfort-focused care.
C. Tell the client she should discuss this decision with her family. While family involvement can be helpful, the decision to continue or stop dialysis is ultimately the client’s right. Encouraging discussion is appropriate, but the nurse should not imply that the client must consult others before making a personal healthcare decision.
D. Support the client's decision to stop the treatment. Autonomy is a fundamental ethical principle in nursing. Clients have the right to make their own healthcare decisions, including the choice to discontinue dialysis. The nurse should offer emotional support, provide palliative care options, and ensure the client’s comfort during the transition.
Correct Answer is C
Explanation
A. "My child still wets the bed at least two times per week." Bedwetting (nocturnal enuresis) is common in young children, and while it can be concerning, it is not uncommon for a 4-year-old. Many children still experience bedwetting at this age, and it usually resolves over time.
B. "My child continually asks me the same questions." Continually asking the same questions can be typical for a 4-year-old, as children often seek clarification and reassurance through repetitive questioning. While it may be frustrating, it is generally not a sign of a serious issue.
C. "I have noticed that my child is withdrawn since we switched day care providers." Withdrawal can be a sign of emotional distress, anxiety, or adjustment issues related to the change in daycare. The nurse should further assess the child's emotional and behavioral responses to ensure they are receiving the appropriate support and intervention if needed.
D. "I have a difficult time getting my child to eat green vegetables." Getting the child to eat green vegetables is a common challenge among young children, as they often exhibit food preferences and may be picky eaters. While it is important to encourage healthy eating habits, this issue does not require immediate intervention compared to concerns about emotional withdrawal.
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