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Questions 227

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Extract:

The nurse assesses a patient's IV site and finds that it is red, hot, and tender to touch.


Question 1 of 5

The most appropriate first nursing action is:

Correct Answer: A

Rationale: Signs of phlebitis or infection require stopping the infusion and removing the IV to prevent further complications.

Extract:

The patient with ascites has a paracentesis and 1500 ml of fluid is removed.


Question 2 of 5

Immediately following the procedure it is most important for the nurse to observe for:

Correct Answer: A

Rationale: A rapid, thready pulse indicates hypovolemia or shock post-paracentesis, a critical complication.

Extract:


Question 3 of 5

Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:

Correct Answer: B

Rationale: Sudden, simultaneous symptoms in a group suggest chemical exposure, likely affecting the respiratory system. The other conditions are less likely to cause acute, collective symptoms. Safety and Infection Control

Question 4 of 5

The parents of a 7 year-old tell the nurse their child has started to 'tattle' on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents?

Correct Answer: A

Rationale: The ethical sense and feelings of justice are developing. At age 7, children develop a sense of justice and fairness.

Extract:

Given Mr. Smith's clinical picture


Question 5 of 5

Which of the following would be the first diagnostic tests that must be performed?

Correct Answer: A

Rationale: Given suspicion of a stroke, the first test to perform would be a CT scan to determine the presence or absence of hemorrhage.

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