Extract:

Question 1 of 5

A nurse is assisting with the care of a client who is receiving a continuous IV infusion of normal saline. Which of the following actions should the nurse take?

A. Change the IV site every 24 hr.B. Monitor the client for signs of phlebitis.C. Flush the IV line with heparin every 4 hr.D. Administer the infusion at a rate of 100 mL/hr.

Correct Answer: B

Rationale: Phlebitis (e.g., redness, pain) is a risk with IV infusions, requiring monitoring. Site changes are every 72-96 hr, heparin isn't routine, and rate depends on orders.

Question 2 of 5

A nurse is assisting with the care of a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

A. Keep the client's leg in a dependent position.B. Monitor the client for signs of bleeding every 4 hr.C. Apply ice packs to the surgical site as prescribed.D. Instruct the client to avoid using a continuous passive motion machine.

Correct Answer: C

Rationale: Ice packs reduce swelling and pain post-arthroplasty. Elevation, frequent bleeding checks, and CPM use are standard.

Question 3 of 5

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

A. Warm the dialysate solution to 45Â°C (113Â°F).B. Monitor the client for signs of peritonitis.C. Add heparin to the dialysate solution per standing orders.D. Flush the catheter with dextrose 5% in water between exchanges.

Correct Answer: B

Rationale: Monitoring for peritonitis (e.g., cloudy effluent, pain) is key in peritoneal dialysis. Dialysate is warmed to body temp (37Â°
C), heparin may be added, and saline flushes are used.

Question 4 of 5

A nurse is assisting with the care of a client who is postoperative following a cesarean birth. Which of the following actions should the nurse take?

A. Monitor the client's incision site every 8 hr.B. Encourage the client to remain in a supine position.C. Instruct the client to splint the incision when coughing.D. Administer a PRN laxative 12 hr postoperative.

Correct Answer: C

Rationale: Splinting the incision reduces pain and strain during coughing post-cesarean. Monitoring should be more frequent, supine isn't ideal, and laxatives depend on need.

Question 5 of 5

A nurse is reinforcing teaching with a client who has a new prescription for montelukast. Which of the following statements should the nurse include?

A. You should take this medication in the morning.B. You might notice an increase in your asthma symptoms initially.C. This medication might cause you to feel drowsy.D. You should stop taking this medication if your symptoms improve.

Correct Answer: C

Rationale: Montelukast can cause drowsiness, a side effect to note. It's taken at night, improves symptoms over time, and stopping risks recurrence.