what is the most appropriate intervention for a client with phlebitis at the iv site
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. What is the most appropriate intervention for a client with phlebitis at the IV site?

Correct answer: B

Rationale: The most appropriate intervention for a client with phlebitis at the IV site is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and continuing the IV can lead to complications such as infection or thrombosis. Applying a warm compress may provide symptomatic relief but does not address the root cause. Increasing the IV flow rate is not indicated and may worsen the inflammation. Monitoring for signs of infection is important, but the priority is to remove the source of inflammation by discontinuing the IV.

2. How should a healthcare provider manage a patient with dehydration?

Correct answer: D

Rationale: Dehydration management involves a comprehensive approach that includes monitoring fluid intake to assess the severity of dehydration, encouraging oral rehydration to replenish fluids orally if the patient can tolerate it, and administering IV fluids in severe cases where oral intake is insufficient. Choosing just one of these options may not address the diverse needs of patients with dehydration. Therefore, selecting 'All of the above' is the most appropriate response as it encompasses the various strategies required for effective dehydration management.

3. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.

4. What are the early signs of hypoglycemia in a diabetic patient?

Correct answer: A

Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.

5. A client is receiving furosemide. Which of the following laboratory values should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Potassium. Furosemide is a loop diuretic that can cause potassium depletion through increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to cardiac dysrhythmias, muscle weakness, and other serious complications. Monitoring sodium, calcium, and magnesium levels is not typically associated with furosemide therapy, making choices A, C, and D incorrect.

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