A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

Correct Answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

Correct Answer: B

Rationale: The correct instruction the nurse should include is to 'Rest as needed throughout the day.' Fatigue is a common symptom of multiple sclerosis (MS), and adequate rest is essential to manage it effectively. Resting as needed helps conserve energy and prevent fatigue from worsening. Choices A, C, and D are incorrect. 'Exercise to the point of exhaustion' is not recommended as it can lead to increased fatigue. 'Avoiding physical activity' entirely is not advisable as appropriate exercise can help maintain strength and energy levels. 'Exercising only once per week' may not be sufficient to combat fatigue and maintain overall well-being in clients with MS.

Correct Answer: A

Rationale: When managing care for a patient with a wound infection, administering prescribed antibiotics is crucial. Antibiotics are necessary to treat the infection and prevent it from worsening. While cleaning the wound with saline and applying a sterile dressing are important components of wound care, the primary treatment for a wound infection is antibiotics. Monitoring for signs of sepsis is also essential, but administering antibiotics promptly is the most critical step in managing a wound infection.

Correct Answer: C

Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.

Correct Answer: D

Rationale: The correct answer is D because waiting 1 minute between puffs ensures proper absorption of the medication. Choice A is incorrect as rinsing the mouth is not a specific instruction related to using the inhaler. Choice B is incorrect as waiting 5 minutes between puffs is longer than necessary. Choice C is incorrect as the timing of medication administration is not specified in the question.

Correct Answer: D

Rationale: The correct answer is to replace the NG tube with a new one. When a client with an NG tube experiences nausea and decreased gastric secretions, it indicates a possible problem with the tube itself. Replacing the tube ensures proper functioning and can alleviate the symptoms. Increasing the suction pressure (Choice A) can worsen the client's condition. Turning the client onto their side (Choice B) may be helpful in some situations but does not address the underlying issue. Irrigating the NG tube with sterile water (Choice C) is not the priority and may not resolve the problem.

Correct Answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

Correct Answer: A

Rationale: Correct answer: When managing a patient with suspected infection, it is crucial to monitor vital signs like temperature, heart rate, blood pressure, and respiratory rate to assess the severity of the infection. Administering antibiotics is also essential to treat the infection. Choice B is incorrect because while checking for fever and monitoring white blood cell count are important, they alone are not sufficient to manage the patient. Choice C focuses on assessing pain and localized swelling, which are important but not primary in managing suspected infection. Choice D mentions monitoring for chills and administering fluids, which are not the primary interventions for managing a suspected infection.

Correct Answer: A

Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.