Correct Answer: D

Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.

Correct Answer: B

Rationale: The correct answer is B: Report of headache and stiff neck. This finding indicates a potential complication of epidural anesthesia called a post-dural puncture headache, which can lead to serious consequences like meningitis or subdural hematoma. The nurse should act immediately by notifying the healthcare provider for further evaluation and management. Redness at the catheter insertion site (A) may indicate local inflammation but doesn't require immediate intervention. Temperature elevation (C) could be a sign of infection but isn't as urgent as a headache and stiff neck. Pain rating of 8 (D) is important but doesn't indicate an immediate threat to the client's health like a post-dural puncture headache.

Correct Answer: C

Rationale: Correct Answer: C Rationale: Asking the patient about allergies to latex or iodine is crucial before starting the IV insertion process. This step ensures patient safety and prevents potential allergic reactions. Knowing the patient's allergies allows the nurse to select appropriate materials for the procedure, reducing the risk of complications. Summary of Other Choices: A: Leaving one hand ungloved is not recommended as it compromises infection control practices. B: Cleansing the skin with normal saline is important but should come after confirming allergies to latex or iodine. D: Removing excessive hair from the site is unnecessary and not a standard practice for starting the IV insertion process.

Correct Answer: D

Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health. Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.

Correct Answer: C

Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia. Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign. Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm. Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability. Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.