When assessing a patient with an intravenous line in the right arm, the LPN notices that the skin near the infusion site is taut and cool, and when the arm is lowered, it appears to swell. What is most likely occurring?
a. Infection
b. Venous spasm
c. Infiltration
d. Embolism
ANS: C
These are symptoms of infiltration. Warmth and redness accompany infection, pain is present with venous spasm, and embolism will cause systemic symptoms.
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A 48-year-old patient with acromegaly is not a candidate for other therapy. What medication, administered subcutaneously, would the nurse caring for the patient expect the physician to order?
A) Gonadorelin hydrochloride (Factrel) B) Octreotide (Sandostatin) C) Nafarelin (Synarel) D) Gonadorelin acetate (Lutrepulse)
The nurse is instructing on home care after placement of an automatic implanted cardioverter defibrillator (AICD). Which statement, made by the client, needs clarification by the nurse?
A) "I need to notify my cardiologist if I feel frequent kicks to the chest." B) "I can continue to work with my power tools." C) "I need to stay away from microwaves." D) "I should opt for a hand search at the airport instead of metal detector scan."
The nurse would explain that the client's diagnosis of interstitial pneumonia means
a. pus has accumulated in the major bronchi. b. the alveoli are filled with fluid. c. the small bronchioles are inflamed. d. there is an inflammatory response in the tissue surrounding the air space.
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use?
a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.