A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Remove the IV catheter.

Apply warm or cold compresses.

Stop the infusion.

Apply a sterile dressing.

Elevate the extremity.

Answer and Explanation

The Correct Answer is C,A,D,E,B

Here’s the correct order of actions a nurse should take when infiltration is identified at an IV site: C. Stop the infusion A. Remove the IV catheter D. Apply a sterile dressing E. Elevate the extremity B. Apply warm or cold compresses ? Rationale: Stopping the infusion prevents further infiltration. Removing the catheter eliminates the source of fluid leakage. Applying a sterile dressing protects the site from infection. Elevation helps reduce swelling. Compresses (warm for older infiltrations, cold for recent ones) promote absorption and comfort.

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Correct Answer is B

Explanation

Choice A rationale:
Giving the client access to a video about diabetes is a good teaching tool, but it should come after assessing the client’s knowledge.
Choice B rationale:
The first step in patient education is to assess the client’s learning needs. This includes determining what the client already knows about managing diabetes.
Choice C rationale:
Establishing short-term, realistic goals for the client is important, but it should be done after assessing the client’s knowledge.
Choice D rationale:
Evaluating the effectiveness of the client’s admission teaching plan is a later step, after assessing the client’s knowledge and teaching them about their condition.

A. Obtain a pair of slipper-socks for the client. B. Increase the client's oral fluid intake. C. Rub the client's feet briskly for several minutes. D. Place a moist heating pad under the client's feet.

Correct Answer is A

Explanation

Choice A rationale:
Providing warm slipper-socks can help increase the client’s comfort by keeping their feet warm.
Choice B rationale:
Increasing the client’s oral fluid intake would not directly affect the temperature of their feet.
Choice C rationale:
Rubbing the client’s feet briskly for several minutes could potentially harm the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Choice D rationale:
Placing a moist heating pad under the client’s feet could potentially burn the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.

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A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.).

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A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).