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 C

Explanation

A. "Request that the nurses show their nursing license prior to removing your newborn from the room." While it's important to ensure that only authorized personnel handle the newborn, asking for nursing licenses is not practical and may not be feasible in a busy clinical environment. Instead, parents should be encouraged to verify the identity of staff based on hospital protocols.
B. "Leave your newborn in the bassinet in your room while you use the bathroom." Leaving the newborn unattended, even in the bassinet, is not advisable. Parents should take their newborn with them if possible or ask for help from staff to ensure the baby's safety while they are away.
C. "Alert the staff if any of your newborn's identification bands are missing." Alerting staff about missing identification bands is crucial for the safety of the newborn. Identification bands help prevent abductions and ensure that the correct infant is returned to the right mother. Parents should be vigilant and report any issues immediately.
D. "Carry your newborn back to the nursery in your arms when you need to rest." Carrying the newborn back to the nursery is not recommended for safety reasons. If the parent needs to rest, they should ask the staff to take the baby to the nursery instead, allowing for proper handling and minimizing the risk of falls or accidents.

A. "I should use my inhaler before exercising." B. "I should use my inhaler when I have an asthma attack." C. "I will rinse my mouth and gargle with water after each inhaler treatment." D. "I will take my inhaler treatment before each meal and at bed time."

Correct Answer is C

Explanation

A. "I should use my inhaler before exercising." Budesonide is an inhaled corticosteroid used for long-term asthma control, not for immediate prevention of exercise-induced bronchospasm. A short-acting beta-agonist (e.g., albuterol) should be used before exercise to prevent bronchospasm.
B. "I should use my inhaler when I have an asthma attack." Budesonide is not a rescue inhaler. It is used daily to reduce airway inflammation and prevent asthma exacerbations. During an acute asthma attack, a fast-acting bronchodilator, such as albuterol, should be used instead.
C. "I will rinse my mouth and gargle with water after each inhaler treatment." Rinsing the mouth after using an inhaled corticosteroid helps prevent oral candidiasis (thrush), a common side effect of steroid inhalers. This practice also reduces irritation and hoarseness associated with corticosteroid use.
D. "I will take my inhaler treatment before each meal and at bedtime." Budesonide is not taken on a strict schedule tied to meals or bedtime. It is usually administered once or twice daily, as prescribed, to maintain consistent anti-inflammatory effects.

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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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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.