The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

The nurse applies a tourniquet to assess a vein.

The nurse dons gloves before starting the IV.

The nurse blows on the area cleansed with alcohol to dry it quickly

The nurse cleans the area with an alcohol pad

Answer and Explanation

The Correct Answer is C

A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.

B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.

C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.

D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.

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Correct Answer is A

Explanation

A. Urine specific gravity 1.034: High urine specific gravity (greater than 1.030) indicates concentrated urine, which is a sign of dehydration. This suggests the kidneys are conserving water due to a lack of fluid.

B. Distended neck veins: Distended neck veins usually indicate fluid overload or hypervolemia, not dehydration.

C. BP 146/94 mm Hg: While elevated blood pressure could be a sign of various conditions, it is not a typical indicator of dehydration. Dehydration often leads to low blood pressure.

D. Bounding pulse: A bounding pulse is often associated with fluid overload or fever and does not indicate dehydration. In dehydration, the pulse may be weak or thready.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Answer: I. Temperature
II. Antibiotic therapy

I. Temperature: The client has a fever (37.3°C), which can be a sign of infection or another serious condition. The first priority is to address the fever, as it may indicate a systemic infection, which needs immediate intervention. Fever is usually managed with antipyretics such as acetaminophen.

II. Antibiotic therapy: Since the client has a fever and possible infection, antibiotic therapy should be initiated early (as per the provider’s orders) to treat the suspected infection. Broad-spectrum antibiotics are often started while waiting for culture results.

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The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client in the emergency department. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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