Correct Answer: D

Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.

Correct Answer: A

Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.

Correct Answer: B

Rationale: The correct action for the nurse to take in this situation is to ask the client if she plans to harm herself. This is crucial to assess the client's risk of self-harm or suicide. Providing immediate safety and appropriate interventions is the priority when a client expresses such thoughts. Requesting additional support from the family (Choice A) may be helpful but does not address the immediate safety concern. Informing the client that feeling this way is normal (Choice C) may invalidate her feelings and does not address the safety risk. Suggesting counseling (Choice D) may be beneficial in the long term but is not the immediate priority when assessing for self-harm or suicide risk.

Correct Answer: C

Rationale: The correct answer is C. Asking about the duration of the surgery indicates readiness to learn about the procedure. This question shows that the client is actively seeking information about the surgical process, demonstrating readiness to learn. Choices A, B, and D reflect concerns, specific requests, or statements unrelated to the learning process. They do not directly indicate readiness to absorb information about the upcoming mastectomy.

Correct Answer: C

Rationale: The correct answer is providing nasopharyngeal suctioning for a client who has pneumonia. This task falls within the practical nurse's scope of practice, as it involves direct patient care and basic interventions. Creating a plan of care for a client recovering from a stroke involves critical thinking and comprehensive assessment, which are typically responsibilities of registered nurses. Assessing a pressure injury requires specialized wound care knowledge, often performed by wound care specialists or registered nurses with wound care training. Teaching a client to use a metered-dose inhaler involves patient education and requires a thorough understanding of asthma management, making it more suitable for a registered nurse.