Some more NCLEX Practice
The nurse notes blanching, coolness and edema at the peripheral intravenous [IV] site. On the basis of these findings, the nurse should implement which action? a) Remove the IV b) Apply a warm compress c) Check for a blood return d) Measure the area of infiltration
Remove the IV The client is experiencing infiltration. Bc infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent any further damage. Once the IV is removed, further action should be taken depending on the medication infusing at the time of infiltration per agency protocol but may include aspiration of the fluid from the site, injection of an antidote, application of warm or cool compresses for specified time intervals & elevation of extremity.
The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus [MRSA]. The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client's room? a) Gloves and gown b) Gloves and face shield c) Gloves, gown and face shield d) Gloves, gown and shoe protectors
Gloves, gown and face shield. You need to protect yourself from contracting an infection and requires you to consider the methods of possible transmission of infection based on pt condition. There is potential for splashes of ineffective material occurring during the wound irrigation or suctioning of tracheostomy
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? a) Puzzle b) Toy soldiers c) Large stacking blocks d) A card game with large pictures
Large stacking blocks. Toddlers like to master activities independently such as stacking blocks. Bc toddlers do not have developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play which is more appropriate for a school-age child.
The nurse has received the client assignment for the day. Which client should the nurse assess FIRST? a) The client who needs to receive subcutaneous insulin before breakfast b) The client who has a nasogastric tube attached to intermittent suction c) The client who is 2 days postoperative and is complaining of incisional pain d) The client who has a blood glucose level of 50 mg/dL [2.8 mmol/L] and complaints of blurred vision
The client who has a blood glucose level of 50 mg/dL [2.8 mmol/L] and complaints of blurred vision Decide which need is most urgent because of the word 'FIRST.' The client in D has low blood glucose level and symptoms reflective of hypoglycemia. This pt should be assessed first so treatment can be implemented. Although the other clients have needs that require assessment, theirs can wait so the pt in choice D is stabilized.
