A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)

Discontinue the IV line and start a new one in another site.

Apply a warm compress to the IV site.

Elevate the affected extremity on a pillow.

Administer an antihistamine to the client.

Flush the IV line with normal saline.

Answer and Explanation

Correct Answer : A,B,C

A) Correct. The nurse should discontinue the IV line and start a new one in another site. The IV site is showing signs of phlebitis, which is inflammation of the vein caused by mechanical, chemical, or bacterial irritation. Phlebitis can lead to complications such as thrombophlebitis, infection, or extravasation.

B) Correct. The nurse should apply a warm compress to the IV site to promote vasodilation and blood flow, which can help reduce inflammation and pain.

C) Correct. The nurse should elevate the affected extremity on a pillow to facilitate venous return and decrease edema.

D) Incorrect. The nurse should not administer an antihistamine to the client unless prescribed by the health care provider. Antihistamines are used to treat allergic reactions, not phlebitis.

E) Incorrect. The nurse should not flush the IV line with normal saline. Flushing the IV line can worsen the inflammation and increase the risk of infection or thrombus formation.

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Correct Answer is ["A","B","C","D"]

Explanation

A) Correct. The nurse should include reducing sodium intake to less than 2 g per day in the teaching. Sodium can increase fluid retention and blood volume, which can raise blood pressure.

B) Correct. The nurse should include increasing physical activity to at least 30 minutes per day in the teaching. Physical activity can lower blood pressure by strengthening the heart, improving blood circulation, and reducing body weight.

C) Correct. Limiting alcohol consumption to no more than two drinks per day for men and one drink per day for women. Excessive alcohol consumption can raise blood pressure, so moderation is important.

D) Correct. Quitting smoking and avoiding exposure to secondhand smoke. Smoking and exposure to secondhand smoke are significant risk factors for hypertension and other cardiovascular diseases.

E) Incorrect. Taking a nap for 20 minutes every afternoon. While rest and relaxation are important for overall well-being, taking a nap specifically for 20 minutes every afternoon may not be directly related to lowering blood pressure. It's better to focus on the other lifestyle modifications mentioned above.

A. "Store unopened insulin vials in the freezer." B. "Rotate injection sites within the same anatomical region." C. "Mix short-acting and long-acting insulins in the same syringe." D. "Draw up regular insulin before NPH insulin when mixing them."

Correct Answer is D

Explanation

A) Incorrect. The nurse should instruct the client to store unopened insulin vials in the refrigerator, not in the freezer. Freezing can damage the insulin and make it ineffective.

B) Correct. The nurse should instruct the client to rotate injection sites within the same anatomical region, such as the abdomen, thighs, arms, or buttocks. Rotating injection sites can prevent lipodystrophy, which is a disorder of fat metabolism that causes hypertrophy or atrophy of subcutaneous tissue.

C) Incorrect. The nurse should instruct the client not to mix short-acting and long-acting insulins in the same syringe. Mixing different types of insulins can alter their onset, peak, and duration of action and affect blood glucose control.

D) Correct. The nurse should instruct the client to draw up regular insulin before NPH insulin when mixing them in the same syringe. This can prevent contamination of the regular insulin vial with NPH insulin, which can affect its potency and clarity.

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A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a client who has hypertension about lifestyle modifications to lower their blood pressure. Which of the following topics should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is teaching a client who has diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)

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