Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client’s IV infusion site and notes that the site is cool and edematous.
Which of the following actions should the nurse take?
A. Initiate a new IV distal to the initial site.
This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
B. Slow the IV solution rate.
Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
C. Maintain the extremity below the level of the heart.
This action would actually worsen the edema by promoting fluid accumulation at the site.
D. Apply a warm, moist compress.
Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also: Stop the IV infusion. Assess the extent of the infiltration or extravasation. Document the findings. Elevate the affected extremity. Consult with a physician for further instructions and potential treatment.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
The most appropriate action for the nurse to take in this situation is:
d. Apply a warm, moist compress.
Here's why the other options are not recommended:
- a. Initiate a new IV distal to the initial site: This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
- b. Slow the IV solution rate: Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
- c. Maintain the extremity below the level of the heart: This action would actually worsen the edema by promoting fluid accumulation at the site.
Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:
- Stop the IV infusion.
- Assess the extent of the infiltration or extravasation.
- Document the findings.
- Elevate the affected extremity.
- Consult with a physician for further instructions and potential treatment.
Similar Questions
A nurse is caring for a client who is taking tamoxifen to treat breast cancer. The nurse should identify which of the following manifestations as an adverse effect of this medication?
A. Tinnitus.
Choice A is wrong because tinnitus (ringing in the ears) is not a known side effect of tamoxifen.
B. Hot flashes.
Hot flashes are a common side effect of tamoxifen, which is hormone therapy for breast cancer that blocks the action of estrogen. Tamoxifen can cause menopause-like symptoms in women, such as irregular or missing periods, vaginal discharge or bleeding, and mood changes.
C. Urinary frequency.
Choice C is wrong because urinary frequency (needing to urinate more often) is not a known side effect of tamoxifen.
D. Constipation.
Choice D is wrong because constipation (difficulty passing stools) is not a known side effect of tamoxifen.
Full Explanation
Hot flashes are a common side effect of tamoxifen, which is hormone therapy for breast cancer that blocks the action of estrogen.
Tamoxifen can cause menopause-like symptoms in women, such as irregular or missing periods, vaginal discharge or bleeding, and mood changes. Choice A is wrong because tinnitus (ringing in the ears) is not a known side effect of tamoxifen.
Choice C is wrong because urinary frequency (needing to urinate more often) is not a known side effect of tamoxifen.
Choice D is wrong because constipation (difficulty passing stools) is not a known side effect of tamoxifen.
A nurse is consulting a formulary about a client’s new prescription for raloxifene. The nurse should identify that this medication is used to treat which of the following conditions?
A. Osteoporosis.
Raloxifene is a medication used to prevent and treat osteoporosis in postmenopausal women. Osteoporosis is a condition that causes bones to become thin and weak, increasing the risk of fractures. Raloxifene belongs to a class of drugs called selective estrogen receptor modulators (SERMs), which mimic the effects of estrogen on bone density.
B. Deep-vein thrombosis.
Choice B is wrong because raloxifene may increase the risk of deep-vein thrombosis (DVT), a type of blood clot that forms in a vein deep in the body. DVT can cause pain, swelling, and redness in the affected limb, and can lead to serious complications such as pulmonary embolism (PE), a blood clot in the lung. Raloxifene should not be used by people who have or had DVT or PE.
C. Urinary tract infection.
Choice C is wrong because raloxifene is not used to treat urinary tract infection (UTI), an infection that affects the bladder, kidneys, or ureters. UTI can cause symptoms such as burning or pain when urinating, frequent or urgent urination, blood in the urine, or fever. UTI is usually treated with antibiotics.
D. Hypothyroidism.
Choice D is wrong because raloxifene is not used to treat hypothyroidism, a condition that occurs when the thyroid gland does not produce enough thyroid hormone. The thyroid hormone regulates the body’s metabolism, growth, and development. Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, or depression. Hypothyroidism is usually treated with synthetic thyroid hormone replacement.
Full Explanation
Raloxifene is a medication used to prevent and treat osteoporosis in postmenopausal women.
Osteoporosis is a condition that causes bones to become thin and weak, increasing the risk of fractures.
Raloxifene belongs to a class of drugs called selective estrogen receptor modulators (SERMs), which mimic the effects of estrogen on bone density. Choice B is wrong because raloxifene may increase the risk of deep-vein thrombosis (DVT), a type of blood clot that forms in a vein deep in the body. DVT can cause pain, swelling, and redness in the affected limb, and can lead to serious complications such as pulmonary embolism (PE), a blood clot in the lung.
Raloxifene should not be used by people who have or had DVT or PE. Choice C is wrong because raloxifene is not used to treat urinary tract infection (UTI), an infection that affects the bladder, kidneys, or ureters. UTI can cause symptoms such as burning or pain when urinating, frequent or urgent urination, blood in the urine, or fever.
UTI is usually treated with antibiotics.
Choice D is wrong because raloxifene is not used to treat hypothyroidism, a condition that occurs when the thyroid gland does not produce enough thyroid hormone.
Thyroid hormone regulates the body’s metabolism, growth, and development. Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, or depression.
Hypothyroidism is usually treated with synthetic thyroid hormone replacement.
A nurse is providing teaching to a client who has a new prescription for lithium carbonate.
Which of the following instructions should the nurse include?
A. Limit foods containing tyramine.
Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.
B. Decrease your daily sodium intake.
Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity. Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high. The client should maintain a normal sodium intake and drink enough fluids while taking lithium.
C. Take this medication 2 hours before a meal.
Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium. Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood. Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.
D. Report swelling of the feet to your provider.
This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.
Full Explanation
This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.
Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.
Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.
Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.
The client should maintain a normal sodium intake and drink enough fluids while taking lithium.
Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.
Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.
Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.