what should a nurse do when they observe signs of phlebitis in a client receiving iv fluids
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Nursing Elites

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1. What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?

Correct answer: C

Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.

2. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?

Correct answer: A

Rationale: The correct answer is A. Putting the glove on the dominant hand first is a key step in maintaining sterile technique as it reduces the risk of contamination. By covering the dominant hand first, the nurse minimizes the risk of contaminating the other hand during the glove application process. Choices B, C, and D are incorrect. Choice B introduces the concept of a sterile gown, which is not relevant to the question about applying sterile gloves. Choice C is incorrect as putting sterile gloves last does not follow the correct sequence of steps in maintaining sterility. Choice D, while important, is not as critical as covering the dominant hand first when applying sterile gloves.

3. A nurse is caring for a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of hypoglycemia due to the body's response to low blood sugar. During hypoglycemia, the body releases epinephrine, leading to sympathetic nervous system activation. This can result in bradycardia as a compensatory mechanism to preserve glucose for vital organs such as the brain. Tachycardia, hypotension, and diaphoresis are more commonly associated with hypoglycemia when it progresses to severe stages and the body's compensatory mechanisms are overwhelmed.

4. A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?

Correct answer: D

Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.

5. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

Correct answer: D

Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.

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