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

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?

A. Monitor the site for further swelling
B. Remove the catheter and place it in another site
C. Reduce the flow rate of IV fluids
D. Switch to oral hydration

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. How should a healthcare professional manage a patient with a tracheostomy?

A. Monitor airway patency and provide humidified oxygen
B. Provide education on tracheostomy care
C. Suction airway secretions and change tracheostomy ties
D. Provide a high-protein diet and ensure fluid restriction

Correct answer: A

Rationale: Correct answer: Monitoring airway patency and providing humidified oxygen is crucial in managing a patient with a tracheostomy to ensure proper breathing and oxygenation. Ensuring the airway is clear and providing oxygen support are immediate priorities. Providing education on tracheostomy care (Choice B) is important for long-term management but not the immediate priority. Suctioning airway secretions and changing tracheostomy ties (Choice C) are tasks that may be necessary but do not address the primary concern of maintaining airway patency. Providing a high-protein diet and ensuring fluid restriction (Choice D) are unrelated to the immediate management of a tracheostomy.

3. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

A. Implement a regular toileting schedule
B. Encourage the client to wear athletic socks when ambulating
C. Place all four bed rails in the upright position
D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

4. What are the risk factors for stroke, and how can it be prevented?

A. High cholesterol and hypertension; prevent with regular exercise
B. Obesity and smoking; prevent with medication and weight loss
C. Diabetes and alcohol consumption; prevent with regular checkups
D. Lack of exercise and poor diet; prevent with lifestyle changes

Correct answer: A

Rationale: The correct answer is A. High cholesterol and hypertension are significant risk factors for stroke. Regular exercise is an effective way to prevent stroke by managing these risk factors. Choice B is incorrect as while obesity and smoking are risk factors, preventing stroke through medication and weight loss is not the primary method. Choice C is incorrect as diabetes and alcohol consumption are risk factors, but preventing stroke through regular checkups is not as direct as managing cholesterol and hypertension. Choice D is incorrect as lack of exercise and a poor diet are indeed risk factors, but the prevention of stroke through lifestyle changes needs to specifically address high cholesterol and hypertension.

5. A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?

A. Hyperactivity
B. Hypervigilance
C. Restlessness
D. Avoidance of social situations

Correct answer: B

Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.