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Questions 149

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Question 1 of 5

The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.

Correct Answer: C,A,B,D

Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).

Question 2 of 5

During which stage of injury repair does the wound show evidence of erythema and edema, and phagocytosis begins?

Correct Answer: B

Rationale: The inflammation stage (
B) involves erythema, edema, and phagocytosis as the body responds to injury. Other stages (A, C,
D) have different processes.

Question 3 of 5

The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about foot care. Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: daily foot inspection is essential to detect early signs of injury or infection in diabetes

Question 4 of 5

The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

Correct Answer: C

Rationale: Gingival hyperplasia is a common side effect of phenytoin therapy.

Question 5 of 5

A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?

Correct Answer: D

Rationale: Sliced pork is a rich source of thiamine (vitamin B1), which is critical for preventing Wernicke's encephalopathy in clients with alcoholism.

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