a nurse is caring for a client who has developed phlebitis at the iv site what is the next step the nurse should take
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Nursing Elites

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ATI PN Comprehensive Predictor

1. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

2. A client who is postpartum is being taught about breast care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Nursing the baby frequently helps prevent engorgement and discomfort in breastfeeding mothers. Choice A is incorrect because tight-fitting bras can lead to clogged milk ducts and worsen discomfort. Choice C may lead to oversupply issues and is not necessary unless there is a specific indication. Choice D is incorrect as avoiding nursing for extended periods can lead to engorgement and decreased milk supply.

3. What are the primary goals of post-operative care for a patient who has undergone abdominal surgery?

Correct answer: A

Rationale: The correct answer is A: Pain Management. After abdominal surgery, one of the primary goals of post-operative care is to manage the patient's pain effectively to ensure their comfort and promote recovery. While wound care, prevention of complications, and ensuring digestive function are also important aspects of post-operative care, pain management takes precedence as it directly impacts the patient's well-being and recovery process.

4. What are the risk factors for developing Type 2 diabetes?

Correct answer: A

Rationale: The correct answer is A: Obesity, sedentary lifestyle, and poor diet are established risk factors for developing Type 2 diabetes. Obesity puts extra pressure on the body's ability to properly control blood sugar levels. A sedentary lifestyle contributes to weight gain and insulin resistance. Poor diet, especially one high in processed foods and sugary beverages, can also increase the risk of developing Type 2 diabetes. Choices B, C, and D are incorrect because age, gender, family history, smoking, alcohol consumption, and hypertension can impact overall health but are not the primary risk factors for Type 2 diabetes.

5. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?

Correct answer: B

Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.

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