Which needle should the nurse use to administer IV fluids via a client's implanted port?

Answer and Explanation

The Correct Answer is D

A. this is a syringe for administration of small amounts of fluids and medications

B. the syringe administers smaller volumes of IV fluids

C. connecting tubing for administration of IV fluids of peripheral access

D. Connecting tubing that can be used on implanted ports.

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Correct Answer is B

Explanation

A. Swollen feet and ankles: While swelling can indicate fluid retention, it may not necessarily warrant immediate intervention unless it is severe or accompanied by other concerning symptoms.

B. Blood-tinged sputum is the most concerning finding because it suggests pulmonary congestion or pulmonary edema, which can occur due to increased pressure in the pulmonary circulation secondary to mitral valve stenosis. This could indicate acute decompensation of the client’s condition, requiring immediate intervention to prevent respiratory compromise or worsening heart failure.

C. Rapid, regular heart rate (e.g., sinus tachycardia) is a compensatory response to reduced cardiac output and increased demand. While it warrants monitoring and potential treatment, it is not as critical as the presence of blood-tinged sputum, which signals acute pulmonary involvement

D. Elevated blood pressure: While elevated blood pressure may indicate increased cardiac workload, rapid, irregular heart rate is a more immediate concern in this context due to its potential to cause complications such as thromboembolism

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Place an indwelling urinary catheter and institute strict intake and output measurements. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Secure client consent for coronary angiography and percutaneous coronary intervention.

Correct Answer is C

Explanation

A. Evaluating upper and lower extremities for perfusion, pulse volume, and pitting edema is important in assessing peripheral perfusion, but the priority action in this scenario is to initiate treatment for a suspected myocardial infarction.
B. Placing an indwelling urinary catheter and instituting strict intake and output measurements is not the priority action in this scenario. The client's symptoms and history suggest a cardiac event requiring immediate intervention.
C. Administering four 81 mg aspirin tablets (324 mg total) as soon as possible is the priority action for a client presenting with chest pain suggestive of acute coronary syndrome. Aspirin helps to prevent platelet aggregation and reduce the risk of clot formation.
D. Securing client consent for coronary angiography and percutaneous coronary intervention may be necessary but is not the immediate priority. The client needs immediate treatment to alleviate symptoms and stabilize the condition.

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Which needle should the nurse use to administer IV fluids via a client's implanted port?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

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