A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

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Question 1 of 5

A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

Correct Answer: C

Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.

Question 2 of 5

What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Correct Answer: A

Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.

Question 3 of 5

The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light while the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?

Correct Answer: B

Rationale: The charge nurse's first action should be to close the demographic screen on the computer to protect patient confidentiality and prevent unauthorized access to sensitive information. This immediate response addresses the breach of patient privacy and ensures that patient data is secure, setting the right priority in managing the situation.

Question 4 of 5

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

Correct Answer: A

Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.

Question 5 of 5

What is the most effective way to implement a teaching plan?

Correct Answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

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