Question

A patient receiving IV fluids reports swelling and coolness at the IV site. The IV fluid is not dripping properly, and the skin looks pale. What is the priority nursing action?

Answer 1

Correct Answers:

Discontinue IV, elevate limb, apply compress, restart in new site

Rationale :

💉 The described symptoms — swelling, coolness, pallor, and slow infusion — indicate IV infiltration, where fluid leaks into surrounding tissue instead of the vein.

💉 The nurse’s priority is to stop the IV immediately to prevent further tissue damage and extravasation.

💉 The affected limb should be elevated to promote venous return, and warm or cold compresses applied depending on the fluid type (warm for non-vesicant, cold for vesicant).

💉 A new IV line must be started at a different site, preferably on the opposite extremity, to continue therapy safely.

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Answer 2

Correct Answers:

The TB syringe is calibrated in mL, not units, which can cause a medication error

Rationale :

💉 Tuberculin (TB) syringes are calibrated in milliliters (mL), while insulin syringes are calibrated in units, which are not interchangeable.

💉 Using a TB syringe for insulin administration can lead to a 10-fold dosing error, resulting in severe hypoglycemia or death.

💉 Insulin must only be measured using a U-100 or U-500 insulin syringe, depending on concentration.

💉 This scenario highlights the importance of using the right equipment for the right medication to prevent medication errors.

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Answer 3

Correct Answers:

Duration of contact with the skin
Size of the affected area
Hydration of the tissues
Drug concentration

Rationale :

🌿 Duration of contact with the skin

🌿 The longer the medication remains in contact with the skin surface, the greater the opportunity for the drug molecules to diffuse through the epidermis and reach systemic circulation.

🌿 Medications applied for extended periods—such as transdermal patches (e.g., fentanyl, nitroglycerin)—provide continuous absorption and maintain a stable therapeutic blood level.

🌿 Conversely, removing the medication too soon reduces the dose absorbed and may make the therapy ineffective.

🌿 This principle underscores the importance of following timing instructions precisely for percutaneous or transdermal applications.

🌿 Size of the affected area

🌿 The total surface area available for application directly affects the rate and amount of absorption. Larger areas allow for more medication molecules to cross through the skin barrier.

🌿 For example, applying a topical corticosteroid to a large surface area increases systemic absorption and risk for side effects compared to application on a small area.

🌿 Nurses must apply medication only to the prescribed region, as covering more skin may lead to overdosage or systemic toxicity.

🌿 The nurse should also ensure that the medication is spread evenly and thinly to ensure uniform absorption.

🌿 Hydration of the tissues

🌿 Well-hydrated skin has greater permeability because moisture softens the stratum corneum, allowing medication molecules to pass through more easily.

🌿 Dry or cracked skin can create an irregular barrier, resulting in inconsistent or decreased absorption.

🌿 For optimal results, some topical medications are applied after bathing when the skin is warm and hydrated, improving uptake.

🌿 Nurses should educate patients that maintaining skin hydration and integrity enhances the effectiveness of percutaneous drugs.

🌿 Drug concentration

🌿 A higher drug concentration creates a stronger diffusion gradient, allowing more medication to move from the surface into deeper tissue layers.

🌿 For example, a 2% hydrocortisone cream provides greater absorption than a 0.5% formulation when applied to the same area for the same duration.

🌿 However, higher concentrations can also increase the risk of local irritation or systemic effects, especially with potent drugs.

🌿 Nurses should always apply medications according to the prescribed concentration and caution patients against using more than directed, as “more” does not mean “better.”

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Answer 4

Correct Answers:

“I’ll take a quick, deep breath to inhale the powder medication.”

Rationale :

💉 Dry-powder inhalers (DPIs) deliver medication that depends on inspiratory effort, requiring a rapid, deep inhalation to disperse the powder into fine particles for lung deposition.

💉 The client should exhale fully first, place lips around the mouthpiece, and then inhale quickly and deeply through the mouth.

💉 Unlike metered-dose inhalers (MDIs), DPIs do not require shaking or hand-breath coordination, and the medication is breath-activated.

💉 Proper DPI use ensures that the medication reaches the lower airways, improving bronchodilation and therapeutic effect.

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Answer 5

Correct Answers:

18G

Rationale :

💉 Blood transfusions require a large-bore catheter (18- or 20-gauge) to allow rapid flow of blood products and reduce hemolysis risk.

💉 An 18-gauge catheter is ideal for adults, ensuring the transfusion proceeds efficiently without clot formation or mechanical damage to red blood cells.

💉 Smaller catheters (22G or 24G) are typically used for children or patients with fragile veins, but they slow the infusion rate and increase clot risk.

💉 Before transfusion, the nurse must verify the order, check crossmatch compatibility, and monitor for transfusion reactions during the first 15 minutes

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Answer 6

Correct Answers:

“You may be experiencing rebound congestion from overuse of the nasal spray.”

Rationale :

💊 Overuse of topical nasal decongestants (such as oxymetazoline or phenylephrine) for more than 3–5 days can cause rhinitis medicamentosa, also known as rebound congestion.

💊 The medication causes initial vasoconstriction, but prolonged use leads to rebound vasodilation, worsening nasal stuffiness when the drug wears off.

💊 The nurse should advise the client to gradually discontinue the spray and consider alternative treatments such as saline nasal sprays or corticosteroid sprays for chronic congestion.

💊 Patient education should include proper use of OTC drugs and avoiding dependency on short-term decongestants.

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Answer 7

Correct Answers:

Stop the procedure, assess the client’s heart rate and blood pressure, and position the client supine with legs elevated

Rationale :

💊 The client is showing signs of a vasovagal response (nausea, dizziness, pallor, diaphoresis) due to stimulation of the vagus nerve during rectal insertion.

💊 The first nursing action is to stop the procedure immediately to prevent syncope and injury.

💊 The nurse should assess vital signs (especially heart rate and blood pressure) and position the client supine with legs elevated to improve venous return and cerebral perfusion.

💊 Once stable, the nurse can explain the reaction, document the event, and notify the provider before proceeding with future rectal medications.

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Answer 8

Correct Answers:

I will clean and dry the the area before applying the patch

Rationale :

💊 For transdermal patches, clean and dry skin ensures proper adhesion and consistent absorption of the medication.

💊 The site should be free of oils, lotions, or moisture, which can interfere with patch adherence and drug delivery.

💊 The nurse should teach the client to rotate application sites with each new patch to prevent skin irritation and buildup of medication in one area.

💊 The old patch must be removed and disposed of properly before applying a new one to avoid accidental overdose.

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Answer 9

Correct Answers:

Capsules have higher bioavailability and act more quickly

Rationale :

💊 Capsules contain medication in powder or liquid form encased in a gelatin shell, which dissolves rapidly in the stomach or intestines.

💊 This allows for faster absorption and quicker onset of action compared to compressed tablets, which must disintegrate before dissolving.

💊 Capsules also mask unpleasant tastes or odors, improving patient compliance, especially in those sensitive to bitter medications.

💊 However, capsules should never be split or crushed, as this alters the drug’s release properties and effectiveness.

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Answer 10

Correct Answers:

1 mL tuberculin syringe with a 26–27 gauge needle

Rationale :

💊 A PPD (purified protein derivative) test for tuberculosis is administered intradermally, requiring precise small-volume measurement (0.1 mL).

💊 The correct equipment is a 1 mL tuberculin syringe with a 26–27 gauge, ⅜- to ½-inch needle, inserted at a 15° angle with the bevel up.

💊 This technique forms a small, raised wheal or bleb, indicating correct intradermal placement.

💊 Larger syringes or needles are inappropriate because they deliver medication too deeply, invalidating the test result.

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QLexNursing

1 :
A patient receiving IV fluids reports swelling and coolness at the IV site. The IV fluid is not dripping properly, and the skin looks pale. What is the priority nursing action?

2 :
A nursing student accidentally selects a tuberculin syringe to administer insulin. What is the primary safety concern?

3 :
Which factors can influence the absorption of topical (percutaneous) medications? (Select All that Apply.)

4 :
A nurse is evaluating a client’s understanding of their dry-powder inhaler (DPI). Which statement by the client indicates correct use?

5 :
A nurse is preparing to initiate a blood transfusion for an adult client. Which IV catheter gauge is most appropriate for this procedure?

6 :
Mrs. Green, age 38, reports using an over the counter (OTC) nasal decongestant spray every few hours for the past 10 days to manage her sinus congestion. She tells the nurse her nasal stuffiness now feels worse than before. Which response by the nurse is most accurate?

7 :
A nurse is inserting a rectal suppository when the client suddenly reports dizziness, nausea, and appears pale and sweaty. Which action should the nurse take first?

8 :
A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

9 :
A patient is prescribed a new capsule medication. The nurse explains that the medication is in a gelatin capsule. What is the main advantage of capsules over tablets?

10 :
A nurse is preparing to administer a PPD test. Which syringe should the nurse select?

QLexNursing

1 : A patient receiving IV fluids reports swelling and coolness at the IV site. The IV fluid is not dripping properly, and the skin looks pale. What is the priority nursing action?

2 : A nursing student accidentally selects a tuberculin syringe to administer insulin. What is the primary safety concern?

3 : Which factors can influence the absorption of topical (percutaneous) medications? (Select All that Apply.)

4 : A nurse is evaluating a client’s understanding of their dry-powder inhaler (DPI). Which statement by the client indicates correct use?

5 : A nurse is preparing to initiate a blood transfusion for an adult client. Which IV catheter gauge is most appropriate for this procedure?

6 : Mrs. Green, age 38, reports using an over the counter (OTC) nasal decongestant spray every few hours for the past 10 days to manage her sinus congestion. She tells the nurse her nasal stuffiness now feels worse than before. Which response by the nurse is most accurate?

7 : A nurse is inserting a rectal suppository when the client suddenly reports dizziness, nausea, and appears pale and sweaty. Which action should the nurse take first?

8 : A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

9 : A patient is prescribed a new capsule medication. The nurse explains that the medication is in a gelatin capsule. What is the main advantage of capsules over tablets?

10 : A nurse is preparing to administer a PPD test. Which syringe should the nurse select?

1 :
A patient receiving IV fluids reports swelling and coolness at the IV site. The IV fluid is not dripping properly, and the skin looks pale. What is the priority nursing action?

2 :
A nursing student accidentally selects a tuberculin syringe to administer insulin. What is the primary safety concern?

3 :
Which factors can influence the absorption of topical (percutaneous) medications? (Select All that Apply.)

4 :
A nurse is evaluating a client’s understanding of their dry-powder inhaler (DPI). Which statement by the client indicates correct use?

5 :
A nurse is preparing to initiate a blood transfusion for an adult client. Which IV catheter gauge is most appropriate for this procedure?

6 :
Mrs. Green, age 38, reports using an over the counter (OTC) nasal decongestant spray every few hours for the past 10 days to manage her sinus congestion. She tells the nurse her nasal stuffiness now feels worse than before. Which response by the nurse is most accurate?

7 :
A nurse is inserting a rectal suppository when the client suddenly reports dizziness, nausea, and appears pale and sweaty. Which action should the nurse take first?

8 :
A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

9 :
A patient is prescribed a new capsule medication. The nurse explains that the medication is in a gelatin capsule. What is the main advantage of capsules over tablets?

10 :
A nurse is preparing to administer a PPD test. Which syringe should the nurse select?