a nurse is assessing a client who reports pain and redness at the site of a peripheral iv what should the nurse do first
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?

Correct answer: B

Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.

2. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?

Correct answer: B

Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.

3. A nurse is preparing to administer a medication to a client with a nasogastric (NG) tube. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when administering medication to a client with a nasogastric (NG) tube is to flush the NG tube with 30 mL of water before administration. Flushing the tube with water helps ensure the patency of the tube and prevents clogging. Choice A is incorrect because administering the medication with a straw is not a recommended practice for NG tube administration. Choice C is incorrect because crushing all medications together may lead to potential drug interactions. Choice D is incorrect because mixing the medication with pudding is not a standard method for administering medication through an NG tube.

4. A nurse is providing discharge teaching to a client who has a prescription for home oxygen therapy. What should the nurse teach?

Correct answer: C

Rationale: The correct answer is C: 'Use cotton fabrics when oxygen is in use.' When a client is on oxygen therapy, it is essential to use cotton fabrics to reduce the risk of static electricity, which can ignite in the presence of oxygen. Choices A, B, and D are incorrect. Removing the oxygen tubing during meals is not necessary as long as proper precautions are taken to avoid tripping hazards. Synthetic fabrics should be avoided while using oxygen therapy to prevent static electricity buildup. Increasing oxygen flow during physical activity should be done according to the healthcare provider's instructions, not indiscriminately.

5. A nurse enters a client's room and sees smoke coming from the trash can. What action should the nurse take first?

Correct answer: B

Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.

Similar Questions

A nurse is planning to teach a group of older adults about the prevention of osteoporosis. What information should the nurse include in the teaching?
A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?
A client has a new prescription for a cane. What instruction should the nurse include?
A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses