the nurse is caring for a client with an intravenous infusion of normal saline the client reports pain and swelling at the iv site what is the nurses
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse’s priority action?

Correct answer: C

Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.

2. A nurse in a pediatric unit is preparing to administer medication to a child. What should the nurse do to ensure the correct dosage?

Correct answer: D

Rationale: When administering medication to children, it is crucial to ensure the correct dosage to prevent dosing errors. Double-checking the dosage calculations with another nurse can help verify the accuracy of the prescribed dose, reducing the risk of medication errors. While checking the child's weight (Choice A) is important for dosage calculation, it alone may not ensure the correctness of the dosage. Verifying the medication order with a pharmacist (Choice B) is essential, but it may not directly address the accuracy of dosage calculations. Consulting the child's parents (Choice C) is not a standard practice for verifying medication dosages and should not be solely relied upon for ensuring the correct dosage.

3. A client is admitted with Atrial Fibrillation and is administered amiodarone (Cordarone). What therapeutic response should the nurse anticipate?

Correct answer: A

Rationale: The correct answer is A: Conversion of irregular heart rate to regular heart rhythm. Amiodarone is a medication commonly used to restore and maintain normal heart rhythm in clients with atrial fibrillation. It works by slowing down the electrical signals in the heart, helping to regulate the heartbeat. Choices B, C, and D are incorrect because they do not directly relate to the therapeutic response expected from administering amiodarone in a client with atrial fibrillation. Pulse oximetry readings, peripheral pulses, capillary refill, and exercise tolerance are important assessments but are not the primary therapeutic goal of using amiodarone in this situation.

4. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?

Correct answer: B

Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.

5. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?

Correct answer: B

Rationale: Reporting signs of bleeding is essential while on anticoagulant therapy to prevent complications.

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