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1. A nurse is caring for a client who has a peripheral IV Stop the IV infusion is cor-
inserted for fluid replacement. rect. The client has mani-
Exhibit 1 festations of IV infiltration.
Nurses' Notes The nurse should stop the
Day 1: IV infusion and remove the
Lactated Ringer's at 100 mL/hr infusing into a IV catheter to reduce the
20-gauge IV catheter in left hand. IV dressing dry and risk for tissue damage.
intact. IV site without redness or swelling. IV fluid in- Elevate the client's left
fusing well.Day 2: arm is correct. The nurse
IV site edematous. Skin surrounding catheter site taut, should elevate the client's
blanched, and cool to touch. IV fluid not infusing. left hand to decrease
swelling and reduce the
risk for tissue damage.
Apply heat to the client's
left hand is correct. The
nurse should apply heat
to the client's left hand to
reduce swelling and pro-
mote comfort.
2. A nurse is caring for a female client. Bleeding is correct. The
Exhibit 1 client's platelet count is
Medical History less than the expected ref-
Client is receiving chemotherapy for treatment of erence range. Therefore,
breast cancer. the client is at risk for
Exhibit 2 bleeding.
Diagnostic Results Platelet count is correct.
Week 1: The client's platelet count
Hct 42% (37% to 47%)Hgb 15 g/dL (12 to 16 g/dL)WBC is less than the expected
count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count reference range. There-
350,000/mm3 (150,000 to 400,000/mm3)Potassium fore, the client is at risk for
3.7 mEq/L (3.5 to 5 mEq/L)Week 2: bleeding.
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, RN Fundamentals Online Practice 2023 B
Study online at https://quizlet.com/_ej1d5l
Hct 37% (37% to 47%)Hgb 12 g/dL (12 to 16 g/dL)WBC
count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count
100,000/mm3 (150,000 to 400,000/mm3)Potassium
3.6 mEq/L (3.5 to 5 mEq/L)
3. A nurse is admitting a client to a health care facility. Wear an N95 mask when
Exhibit 1 caring for the client is
Nurses' Notes correct. The nurse should
1100: identify the client has tu-
Client reports fever, chills, cough, and night sweats for berculosis, which requires
past 2 weeks. Client has recently traveled outside of airborne isolation. There-
the country. Lethargic, but oriented to person, place, fore, the nurse should
and time. Crackles heard in lower lobes of lungs upon wear an N95 mask when
auscultation. Cough is productive with small amounts caring for the client.
of blood. Reports tightness in chest and pain when Place a container for soiled
coughing. Reports losing 5 lb in the last week. Has no linens inside the client's
appetite and is nauseated. Obtained blood work, chest room is correct. The nurse
x-ray, and sputum culture as prescribed. should identify the client
Exhibit 2 has tuberculosis, which
Vital Signs requires airborne isola-
1100: tion. Therefore, the nurse
BP 138/72 mm HgHeart rate 80/minRespirations should place a container
22/minTemperature 38.3° C (101.1° F)Oxygen satura- for soiled linens inside the
tion 90% on room air client's room to prevent
Exhibit 3 transmission of the infec-
Diagnostic Results tion.
1400: Place the client in a nega-
Chest x-ray positive for inflammation and infiltrates in tive airflow room is correct.
upper lobesQuantiFERON-TB positive (negative)Tuber- The nurse should identify
culosis culture positive (negative) the client who has tuber-
culosis should be placed in
a negative airflow pressure
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