a nurse is caring for a client with iv fluids who has developed redness and warmth at the iv site what is the next step the nurse should take
Logo

Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 Quizlet

1. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

2. A nurse is caring for a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of hypoglycemia due to the body's response to low blood sugar. During hypoglycemia, the body releases epinephrine, leading to sympathetic nervous system activation. This can result in bradycardia as a compensatory mechanism to preserve glucose for vital organs such as the brain. Tachycardia, hypotension, and diaphoresis are more commonly associated with hypoglycemia when it progresses to severe stages and the body's compensatory mechanisms are overwhelmed.

3. A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

Correct answer: A

Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.

4. The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.

5. What are the key nursing interventions for a patient undergoing dialysis?

Correct answer: A

Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.

Similar Questions

A client with type 2 diabetes mellitus is being taught about insulin administration by a nurse. Which of the following instructions should the nurse include?
A client who is 1 day postoperative following a total hip arthroplasty should be instructed to do which of the following?
A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?
A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
What is the most important action when providing wound care to a client with a pressure ulcer?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses