During a clinical rotation on an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool, blanched and slightly swollen. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?

Infiltration

Local inflammation

Thrombophlebitis

Phlebitis

Answer and Explanation

The Correct Answer is A

A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.

B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.

C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.

D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

D. The nurse should promptly notify the healthcare provider to discuss the allergy history and request an alternative antibiotic that is not structurally related to penicillin or cephalosporins. Examples of alternative antibiotics may include antibiotics from different classes such as macrolides or fluoroquinolones, depending on the indication and sensitivity profile.

A. Diphenhydramine (Benadryl) is an antihistamine that can help manage allergic reactions. However, it should not be used as a standalone precautionary measure for a client with a history of anaphylaxis to penicillin. Anaphylaxis is a severe allergic reaction that can lead to life-threatening symptoms such as difficulty breathing, swelling, and low blood pressure.

B. Before taking any further steps, the nurse should clarify and confirm the nature and severity of the client's allergic reaction to penicillin. Anaphylaxis is a serious allergic reaction characterized by rapid onset and potentially life-threatening symptoms. Clarifying the history ensures accurate decision- making regarding the administration of cephalexin.

C. This is not recommended without further clarification and assessment. Given the history of anaphylaxis to penicillin, there is a significant risk of cross-reactivity with cephalosporins like cephalexin. Cephalosporins have a structural similarity to penicillin and can provoke allergic reactions in individuals with penicillin allergy, including anaphylaxis.

A. Diarrhea B. Hyperglycemia C. Shortened PR interval D. Headache

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

Explanation

A. Diarrhea is a common side effect associated with ondansetron, which is used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery.

B. Ondansetron can potentially cause changes in glucose metabolism, leading to hyperglycemia, especially in clients with diabetes mellitus. Monitoring blood glucose levels is essential during ondansetron administration, particularly in clients who are already predisposed to hyperglycemia.

D. Headache is a potential adverse effect of ondansetron. It is listed as a common side effect and should be monitored, especially in older adults who may be more sensitive to medication effects.

C. Ondansetron can affect the QT interval rather than the PR interval. It may cause QT interval prolongation, which can predispose the client to arrhythmias

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is collecting data from an older adult client who is receiving ondansetron IV, has a history of diabetes mellitus and cardiac myopathy, and is receiving chemotherapy to treat cancer. For which of the following adverse effects of ondansetron should the nurse monitor? (Select all that apply)

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

Explanation

A client who is taking nitrofurantoin for a urinary tract infection voices a concern to the clinic nurse about experiencing numbness and tingling of the hands and feet. Which of the following is an appropriate response by the nurse?

A nurse is collecting data on a client who has circulatory overload. Which of the following findings should the nurse expect?

A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is mentoring a new nurse who is learning to start IVs. The nurse tells the new nurse that in case the patient needs subsequent venipuncture sites, the best place to initially start an IV is the:

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