After administering an injection, the nurse observes bleeding at the site. In what sequence should the nurse perform these actions? (Arrange with the first step on top and the last step on the bottom.)

Retract the needle into the syringe.

Place syringe in a puncture-resistant container.

Apply an adhesive bandage over the injection site.

Remove disposable exam gloves.

Answer and Explanation

The Correct Answer is A,B,D,C

Choice A: Retracting the needle into the syringe should be done before safely disposing of the syringe.

Choice B: Placing the syringe in a puncture-resistant container is the second step to ensure safe disposal of sharp objects.

Choice C: Applying an adhesive bandage over the injection site is the final step to address the bleeding and protect the site.

Choice D: Removing disposable exam gloves is the next step to prevent any contamination.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A: Checking mental acuity is important for assessing the client's cognitive function, but it may not be the most crucial intervention in the context of left- sided heart failure.

Choice B: Measuring urinary output is a valuable assessment in clients with heart failure, but it is not the most important intervention among the choices provided.

Choice C: Inspecting for sacral edema is a relevant assessment for clients with heart failure, especially when assessing for fluid retention. However, it may not be the highest priority in this case.

Choice D: Auscultating all lung fields is the most important intervention for a client with left-sided heart failure. Left-sided heart failure often results in pulmonary congestion, and auscultating the lung fields can provide critical information about the presence of crackles, wheezes, or other abnormal breath sounds, indicating worsening heart failure.

A. Redness at intravenous site. B. Generalized nonpitting edema. C. Frequent productive cough. D. Hypoactive bowel sounds in all 4 quadrants. E. Urinary output greater than 30 mL per hour.

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

Explanation

Choice A: Redness at the intravenous site may indicate infection or phlebitis, which are complications of TPN.

Choice B: Generalized nonpitting edema may indicate fluid overload, which can occur due to the high osmolarity of TPN.

Choice C: Frequent productive cough may indicate pulmonary edema or aspiration, which are also potential complications of TPN.

Choice D: Hypoactive bowel sounds in all 4 quadrants are not necessarily abnormal, as TPN bypasses the gastrointestinal tract.

Choice E: Urinary output greater than 30 mL per hour is within the normal range and indicates adequate renal function.

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After administering an injection, the nurse observes bleeding at the site. In what sequence should the nurse perform these actions? (Arrange with the first step on top and the last step on the bottom.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Correct Answer is D

Explanation

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

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

Explanation

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