the nurse is caring for a client while fluoruracil 5fu is being infused the client complains of burning at the iv site what should the nurse do first
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Nursing Elites

NCLEX-PN

NCLEX Question of The Day

1. While Fluorouracil (5FUĀ®) is being infused, a client complains of burning at the IV site. What should the nurse do first?

Correct answer: C

Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.

2. Which client should be seen first by the Emergency Department nurse?

Correct answer: C

Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.

3. Which type of exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence?

Correct answer: A

Rationale: The correct answer is Kegel. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, making them an effective treatment for urinary incontinence. These exercises involve contracting and relaxing the pelvic floor muscles, which helps to improve muscle tone and control. Choice B, resistance exercises, may not directly target the pelvic floor muscles as effectively as Kegel exercises. Passive exercises (Choice C) do not actively engage the muscles and are unlikely to strengthen the pelvic floor. Stretching exercises (Choice D) focus on increasing flexibility rather than muscle strength, so they are not the most appropriate for strengthening the pelvic floor muscles in the context of urinary incontinence.

4. A patient who has delivered an 8.2 lb. baby boy 3 days ago via c-section, reports white patches on her breast that aren't going away. Which of the following medications may be necessary?

Correct answer: A

Rationale: The patient is likely experiencing thrush, a fungal infection, which can present as white patches on the breast that persist. Nystatin is an antifungal medication commonly used to treat thrush. Therefore, the correct answer is Nystatin. Atropine is not indicated for this condition and is used for different purposes. Amoxil is an antibiotic and would not be effective against a fungal infection like thrush. Lortab is a pain medication and is not appropriate for treating thrush.

5. The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks to clarify what type of diet he is to follow. Which diet is best for clients with ulcerative colitis?

Correct answer: D

Rationale: The correct answer is 'Low fiber.' Clients with ulcerative colitis should follow a low-residue diet, which means consuming low fiber to reduce the frequency and volume of stools, helping to alleviate symptoms such as abdominal pain and diarrhea. High fiber diets can worsen the condition by stimulating bowel movements. Choice A, 'High vitamin,' is incorrect as the focus is on fiber content rather than vitamins. Choice B, 'High calorie,' is not specifically recommended for ulcerative colitis and may not address the symptoms effectively. Choice C, 'Low sugar,' does not directly address the dietary needs of clients with ulcerative colitis as the issue is more related to fiber intake than sugar consumption.

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