A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

Questions 48

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PN ATI Capstone Fundamentals Quiz Questions

Question 1 of 9

A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

Correct Answer: C

Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration.

Question 2 of 9

A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?

Correct Answer: A

Rationale: Wearing slippers or shoes when out of bed protects the feet from injury, which is crucial for clients with diabetes.

Question 3 of 9

A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skills should the nurse expect?

Correct Answer: A

Rationale: At 15 months, toddlers typically walk independently but may do so with a wide stance for balance.

Question 4 of 9

A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?

Correct Answer: B

Rationale: Using written communication can help ensure that the client understands the information being conveyed.

Question 5 of 9

A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?

Correct Answer: C

Rationale: Having the client sit upright for 1 hour after meals facilitates swallowing and reduces the risk of aspiration.

Question 6 of 9

A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?

Correct Answer: C

Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.

Question 7 of 9

A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

Correct Answer: C

Rationale: The correct order for an abdominal assessment is inspection, auscultation, percussion, and then palpation.

Question 8 of 9

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: B

Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.

Question 9 of 9

A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?

Correct Answer: A

Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.

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