a client is receiving iv fluids and has developed phlebitis what is the next step the nurse should take
Logo

Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2024

1. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?

Correct answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.

2. What are the early signs of heart failure in a patient?

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

3. A client with multiple fractures following a motor-vehicle crash is struggling with opening a milk carton. Which of the following client statements should the nurse recommend a referral to an occupational therapist?

Correct answer: B

Rationale: The correct answer is B. Struggling to open a milk carton indicates difficulty with fine motor skills and activities of daily living. This statement suggests a need for assistance from an occupational therapist to improve hand strength, coordination, and independence in performing essential tasks. Choices A, C, and D do not directly relate to the need for occupational therapy services in this context. In contrast, the inability to open a milk carton highlights specific challenges that occupational therapy can address effectively.

4. What is the priority nursing intervention for a patient with chest pain?

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.

5. How should a healthcare professional assess a patient with fluid overload?

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

Similar Questions

A healthcare provider is providing discharge instructions to a client with home oxygen. What is the most important safety consideration?
A nurse is caring for a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?
A nurse is caring for a client who is postoperative following a thyroidectomy and reports tingling and numbness in the hands. The nurse should expect to administer which of the following medications?
A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?
How do you assess for dehydration in a pediatric patient?

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