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 A

Explanation

A. Case manager. A case manager assists clients in accessing community resources, including financial assistance programs such as WIC (Women, Infants, and Children) and other social services that provide formula for infants. This referral ensures the client receives the necessary support to meet her baby's nutritional needs.
B. Primary care provider. A primary care provider focuses on the client’s medical care rather than financial or social concerns. While they may provide guidance on infant nutrition, they are not the best resource for addressing the client’s financial difficulties in obtaining formula.
C. Nutritionist. A nutritionist provides dietary guidance but does not handle financial assistance programs. They may educate the client on proper infant feeding, but they cannot directly assist with obtaining formula for a client who cannot afford it.
D. Pediatric nurse practitioner. A pediatric nurse practitioner specializes in infant health but does not typically manage financial concerns. They may assess the baby’s growth and nutritional needs but would refer the client to a case manager or social services for formula assistance.

A. Decrease daily fluid intake. B. Rise slowly from a sitting position to a standing position. C. Withhold the medication if pulse rate is less than 60/min. D. Increase dietary potassium.

Correct Answer is B

Explanation

A. Decrease daily fluid intake. Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, can cause hypotension, particularly after the first dose. Decreasing fluid intake could exacerbate hypotension and increase the risk of syncope. Clients should maintain adequate hydration unless otherwise instructed by their provider.
B. Rise slowly from a sitting position to a standing position. Enalapril can cause orthostatic hypotension, especially when starting therapy. Clients should be advised to change positions slowly to reduce dizziness and syncope risk. Lying down if dizziness occurs can help restore blood pressure and prevent falls.
C. Withhold the medication if pulse rate is less than 60/min. Enalapril primarily affects blood pressure rather than heart rate. Unlike beta-blockers or some calcium channel blockers, it does not significantly lower the heart rate. The decision to hold enalapril should be based on blood pressure readings rather than pulse rate.
D. Increase dietary potassium. ACE inhibitors reduce potassium excretion, increasing the risk of hyperkalemia. Clients should be cautious with potassium-rich foods and supplements to avoid dangerous elevations in potassium levels, which can lead to cardiac complications.

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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 collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

Correct Answer is A

Explanation

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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.