IV Therapy & Insulin
The nurse notices coolness, swelling, and pallor at a peripheral IV site. The IV infusion is running slower than expected. What complication does the nurse suspect?
Infiltration
Rationale:
Infiltration occurs when IV fluid leaks into the surrounding tissue. Common findings include coolness, swelling, pallor, discomfort, and a slowed infusion.
This step of the nursing process involves collecting subjective and objective information about the patient.
Assessment
Rationale:
Assessment involves collecting information such as vital signs, symptoms, physical findings, history, and patient statements.
A patient with heart failure is being weighed each morning. The patient's weight has increased by 3 pounds since yesterday. What should the nurse do with this finding?
Assess the patient for additional signs of fluid retention and worsening heart failure
Rationale:
A rapid weight gain can indicate fluid retention. The nurse should assess for edema, lung sounds, respiratory status, blood pressure, and other changes rather than ignoring the weight gain.
A patient with osteoporosis asks the nurse what they can do to decrease their risk for future fractures. What should the nurse assess before developing an individualized teaching plan?
Assess the patient's current activity level, home safety, fall history, and understanding of osteoporosis
Rationale:
The nurse should assess before teaching. Knowing the patient's risks and current understanding allows the nurse to provide appropriate fracture and fall-prevention education.
A patient’s lipid profile shows the following changes over the past year:
Based on these laboratory findings, which condition should the nurse suspect the patient is at increased risk for?
A. Iron-deficiency anemia
B. Cardiovascular disease
C. Acute kidney injury
D. Hypocalcemia
B. Cardiovascular Disease
Rationale:
Total cholesterol ↑ → increased cardiovascular risk
LDL ↑ → increased plaque/atherosclerosis risk
HDL ↓ → less protective effect
Triglycerides ↑ → increased cardiovascular risk
The nurse is preparing to mix regular insulin and NPH insulin in the same syringe. Which insulin should the nurse draw up first?
Regular insulin
Rationale:
When mixing compatible insulins, draw up short/rapid-acting insulin before intermediate-acting insulin. Remember: clear before cloudy and Nancy Reagan Registered Nurse
A patient is scheduled for surgery. Which action is part of preoperative nursing care?
A. Encourage the patient to eat before surgery
B. Verify that required preoperative information is completed
C. Remove all postoperative restrictions
D. Encourage unrestricted activity
B
Rationale:
Preoperative care includes ensuring that required preparation, information, and safety checks are completed before surgery.
A patient with coronary artery disease tells the nurse, "I get this pressure in my chest whenever I walk to the bathroom, but it goes away when I sit down." What should the nurse assess next?
Assess the patient's chest discomfort, including onset, location, quality, severity, duration, and what relieves or worsens it.
Rationale:
The description is concerning for angina. The nurse should perform a focused assessment of the chest discomfort and determine whether the patient's symptoms are consistent with the patient's established pattern or represent a change.
A patient with a fractured femur reports that their pain has suddenly become much worse despite receiving prescribed pain medication. The affected extremity appears swollen. What should the nurse do next?
Perform an immediate neurovascular assessment of the affected extremity
Rationale:
Sudden severe pain that is not relieved by medication can indicate a serious complication such as compartment syndrome. The nurse should assess circulation, sensation, movement, and other neurovascular findings promptly
A patient’s lab results show a WBC count of 14,500/mm³ and neutrophils of 78%. What should the nurse suspect?
An acute bacterial infection or inflammation
Rationale:
An elevated WBC suggests infection or inflammation, while increased neutrophils specifically point toward a bacterial infection. The nurse should assess the patient for signs of infection.
A patient receiving an IV infusion develops redness, warmth, tenderness, and a palpable cord along the vein. The nurse recognizes this as what complication? And what should the nurse do?
phlebitis, Stop IV, remove catheter, elevate extremity, apply cool compress, don't rub the area
Rationale:
Phlebitis is inflammation of the vein. Classic findings include redness, warmth, pain/tenderness, and a cordlike vein.
A patient is 4 hours postoperative following abdominal surgery. During your assessment, the patient reports increasing abdominal pain that is now 9/10 despite receiving pain medication 30 minutes ago. The patient's heart rate has increased from 82 to 112/min. What should the nurse do next?
Perform a focused assessment and reassess the patient's vital signs and surgical site
Rationale:
The patient's increasing pain and tachycardia are changes from baseline that require further assessment. The nurse should not simply assume this is expected postoperative pain. Assessment comes before deciding on the next intervention.
A patient with peripheral vascular disease reports increasing pain in the affected leg. On assessment, the foot is pale and cool compared with the other foot. What is the nurse's priority concern?
Decreased arterial perfusion to the affected extremity
Rationale:
A cool, pale, painful extremity suggests impaired arterial blood flow. The nurse should perform a focused neurovascular assessment and promptly address the change in circulation.
A patient with a long-bone fracture suddenly develops difficulty breathing, confusion, and small red spots on the chest. What should the nurse recognize and what is the priority nursing action?
Recognize possible fat embolism syndrome and immediately assess/support the patient's respiratory status
Rationale:
The combination of respiratory distress, neurologic changes, and petechiae is concerning for fat embolism syndrome. The patient's oxygenation and respiratory status are the immediate priorities.
A nurse is changing a patient's wound dressing and notices that the wound has more drainage than it did during the previous dressing change. The drainage also has a new foul odor. What should the nurse do next?
Assess the wound and surrounding tissue for additional signs of infection and document and report the change
Rationale:
A change in drainage and a new foul odor can indicate infection or a change in wound status. The nurse should perform a focused wound assessment and communicate significant changes.
The nurse is preparing to mix regular insulin and NPH insulin. Which actions should the nurse take? Select all that apply.
A. Inject air into the NPH vial
B. Inject air into the regular insulin vial
C. Withdraw the NPH insulin first
D. Withdraw the regular insulin first
E. Avoid contaminating the regular insulin vial with NPH insulin
F. Shake the insulin vigorously before withdrawing it
A, B, D, and E?
Rationale:
The nurse should: Inject air into the NPH vial, inject air into the regular insulin vial, withdraw regular insulin first, Avoid contaminating the regular insulin vial
A patient is preparing for surgery and tells the nurse, "I signed the consent form, but I honestly don't understand what the heck is going on" What is the nurse's priority action?
Notify the appropriate provider that the patient does not understand the procedure before proceeding with surgery
Rationale:
The nurse should recognize that the patient needs additional information before giving informed consent. The provider performing the procedure is responsible for explaining the procedure, risks, benefits, and alternatives.
A patient with heart failure suddenly becomes short of breath while lying in bed. The nurse hears new crackles in both lungs. What should the nurse do first?
Assess the patient's respiratory status and position the patient to promote breathing
Rationale:
The patient may be developing pulmonary congestion from worsening heart failure. Breathing is the immediate priority. The nurse should assess oxygenation/respiratory status
A patient recovering from fracture repair is reluctant to get out of bed because they are afraid of falling. What should the nurse do to promote mobility while maintaining safety?
Assess the patient's mobility restrictions and strength, then assist the patient with the prescribed activity using the appropriate assistive device and fall precautions
Rationale:
The goal is safe early mobility, not simply keeping the patient on bed rest. The nurse should follow weight-bearing restrictions, use appropriate equipment, and reduce fall risk.
A patient has a wound that requires a specimen for culture. The nurse prepares to collect the specimen but notices that the wound has not yet been cleaned according to the ordered procedure. What should the nurse do?
Follow the prescribed wound-cleaning procedure before collecting the specimen using the appropriate collection technique
Rationale:
Proper collection technique reduces contamination and ensures an accurate culture result.
The nurse enters a patient's room to administer scheduled insulin and assess the patients IV. The patient reports feeling shaky, sweaty, and dizzy. The IV site is swollen and cool to the touch, and the IV pump is alarming that there is an occlusion. What should the nurse do first?
Assess the patient's blood glucose level and immediate condition
Rationale:
The patient's shakiness, sweating, and dizziness are concerning for hypoglycemia, which is an immediate priority. The nurse should assess the blood glucose and patient status before administering insulin. The IV site also needs to be addressed because coolness and swelling suggest infiltration, but the patient's potentially acute hypoglycemia takes priority.
The RN receives report on four patients. One patient is postoperative and has a respiratory rate of 8/min, another reports pain of 8/10, another needs assistance with bathing, and another is asking when they can go home. Which patient should the nurse assess first, and why?
Patient 1
Rationale:
A respiratory rate of 8/min can indicate respiratory depression, which is an immediate threat to the patient's airway and breathing. The nurse should prioritize using ABCs before addressing pain, hygiene, or discharge questions.
A patient with hypertension tells the nurse, "My blood pressure has been high for years, but I don't feel sick, so I don't think it matters." How should the nurse respond using patient education?
Explain that hypertension can be asymptomatic while still causing damage to organs such as the heart, brain, kidneys, and eyes, and assess the patient's understanding of their treatment plan
Rationale:
Patient education should focus on why treatment and monitoring matter, while assessing what the patient already understands.
A patient being treated for osteomyelitis has been receiving therapy but now reports increased pain at the affected area and develops a fever. What should the nurse do first?
Reassess the patient for worsening infection and notify the appropriate provider of the change in condition
Rationale:
Increasing pain and fever may indicate worsening infection or inadequate response to treatment. The nurse should reassess, obtain relevant findings, and communicate the change rather than assuming it is expected.
A patient is admitted with hypovolemia and needs rapid fluid replacement. The nurse needs to select an IV solution that has the same osmolality as plasma and expands the extracellular fluid volume. Which type of IV solution should the nurse expect to administer?
Isotonic solution, such as 0.9% normal saline or Lactated Ringer’s
Rationale:
Isotonic fluids have the same osmolality as plasma and expand the ECF, making them useful for hypovolemia and fluid replacement.