a nurse is caring for a client who has developed phlebitis at the iv site what should the nurse do immediately
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ATI PN Comprehensive Predictor 2023 Quizlet

1. A client has developed phlebitis at the IV site. What should the nurse do immediately?

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.

2. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

Correct answer: B

Rationale: The correct answer is B: 'Demonstrate assertiveness.' For clients with dependent personality disorder, assertiveness training is crucial as it helps them become more independent and develop the skills to express their own needs and preferences effectively. Choice A ('Limit social interactions') is incorrect because promoting healthy social interactions is important for individuals with this disorder to build confidence and reduce dependency. Choice C ('Follow a rigid schedule') is incorrect as overly rigid schedules may exacerbate feelings of helplessness and dependence. Choice D ('Perform deep breathing exercises') is not directly related to addressing the core issues of dependent personality disorder, which primarily involve developing self-reliance and assertiveness.

3. A healthcare professional is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the healthcare professional expect the provider to prescribe for the client?

Correct answer: C

Rationale: Chlordiazepoxide is a benzodiazepine commonly used to manage anxiety and prevent seizures during alcohol withdrawal. Haloperidol (Choice A) is an antipsychotic medication and is not typically used for alcohol withdrawal. Disulfiram (Choice B) is used in the treatment of alcohol use disorder but is not indicated for alcohol withdrawal. Phenobarbital (Choice D) may be used for alcohol withdrawal seizures but is not the first-line medication for managing alcohol withdrawal symptoms.

4. A client with hypertension is asking for lifestyle changes. What should the nurse recommend?

Correct answer: B

Rationale: The correct answer is B: Reduce caffeine and alcohol consumption. This recommendation is crucial for managing hypertension as excessive caffeine and alcohol intake can elevate blood pressure. By reducing these stimulants, the client can help regulate their blood pressure levels. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is contraindicated in hypertension as it can lead to fluid retention and worsen blood pressure. Encouraging increased protein intake (Choice C) and increasing intake of fruits and vegetables (Choice D) are generally healthy dietary suggestions but not specifically targeted at managing hypertension.

5. When reviewing the medical record of a client with dementia, what should the nurse prioritize addressing?

Correct answer: B

Rationale: When caring for clients with dementia, addressing restlessness and agitation is a priority as it can lead to distress, safety risks, and potential harm to the client or others. Restlessness and agitation are common behavioral symptoms of dementia and can indicate unmet needs, discomfort, or confusion. Managing these symptoms promptly can help improve the client's quality of life and prevent complications such as falls, injuries, or escalation of challenging behaviors. While other issues like mild confusion, incontinence, and wandering are also important to address, managing restlessness and agitation takes precedence due to its immediate impact on the client's well-being and safety.

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