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.

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Correct Answer is D

Explanation

A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.

A. Position the car seat at a 90° angle. B. Keep the airbag on if the car seat is in the front seat. C. Put a small cushion under the newborn's head for support. D. Place the shoulder harnesses at the level of the infant's shoulders.

Correct Answer is D

Explanation

A. "Position the car seat at a 90° angle." Positioning the car seat at a 90° angle is not recommended. The car seat should be reclined at an angle of 30 to 45 degrees to ensure that the infant's head does not flop forward, which can obstruct the airway.
B. "Keep the airbag on if the car seat is in the front seat." Keeping the airbag on when a car seat is in the front seat is unsafe. It is recommended to place the car seat in the back seat, as the force of an airbag deploying can be harmful to a child in a car seat.
C. "Put a small cushion under the newborn's head for support." Placing a cushion under the newborn's head is not recommended, as it can interfere with the proper positioning of the car seat and compromise the safety of the infant. The car seat is designed to provide support without additional cushions.
D. "Place the shoulder harnesses at the level of the infant's shoulders." Placing the shoulder harnesses at the level of the infant's shoulders is the correct practice. The harnesses should be positioned snugly at or just above the shoulders for optimal safety, ensuring that the infant is securely restrained in the car seat.

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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.

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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.