Question

A nurse is assessing a client's intravenous (IV) site and suspects infiltration. Which assessment finding best supports this suspicion?

Answer 1

Correct Answers:

The IV site is cool to touch and the infusion is not flowing properly.

Rationale :

👉 IV infiltration occurs when a non-vesicant IV fluid or medication accidentally leaks into the surrounding tissue instead of remaining inside the vein.

👉 A key assessment finding of infiltration is coolness at the IV site because the fluid accumulating in the tissue lowers the temperature of the surrounding skin.

👉 The nurse may also observe:

Swelling or edema

Pale or blanched skin

Tightness around the insertion site

Slowed or stopped IV infusion

Patient reports of discomfort or pressure

👉 A poorly flowing infusion suggests that the catheter may no longer be positioned correctly within the vein.

👉 Early recognition is important because untreated infiltration can cause tissue damage, especially if irritating medications are infused.

👉 The nurse should stop the infusion, remove the catheter, elevate the extremity if appropriate, and restart the IV at another site according to facility policy.

👉 Therefore, coolness and impaired infusion flow are the findings most consistent with IV infiltration.

❌ The IV site shows a small bruise with minimal swelling.

👉 A small bruise may indicate minor trauma during IV insertion or a small hematoma.

👉 It does not specifically indicate infiltration unless accompanied by swelling, coolness, and leaking of fluid into tissues.

❌ The client reports a sharp, shooting pain along the vein.

👉 Sharp pain traveling along the vein is more consistent with phlebitis, which is inflammation of the vein.

👉 Phlebitis commonly presents with:

Redness

Warmth

Tenderness

Pain along the vein

❌ The IV site is red, warm, and tender to touch.

👉 Redness, warmth, and tenderness indicate phlebitis or infection, not infiltration.

👉 Infiltration usually causes the site to become cool, swollen, and pale, rather than warm and red.

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Answer 2

Correct Answers:

Smoking tobacco

Rationale :

👉 Smoking tobacco is a modifiable risk factor because the client can change this behavior to reduce the risk of chronic diseases.

👉 Tobacco use significantly increases the risk of many chronic conditions, including:

Cardiovascular disease

Stroke

Chronic obstructive pulmonary disease (COPD)

Lung cancer

👉 Smoking damages blood vessels, promotes inflammation, and contributes to atherosclerosis.

👉 Smoking cessation reduces disease risk and improves overall health outcomes, even in clients who have smoked for many years.

👉 The nurse should provide education and resources to support smoking cessation, such as counseling, nicotine replacement therapy, and behavioral strategies.

👉 Therefore, smoking tobacco is a modifiable risk factor.

❌ Family history of diabetes

👉 Family history is a nonmodifiable risk factor because a person cannot change their genetic background.

👉 However, clients with a family history can reduce their risk through lifestyle changes such as healthy eating, exercise, and weight management.

❌ Age over 60 years

👉 Age is a nonmodifiable risk factor because it cannot be changed.

👉 The risk of many chronic diseases increases naturally as people get older.

❌ Ethnicity

👉 Ethnicity is a nonmodifiable risk factor because it is related to inherited and population-based characteristics.

👉 Although healthcare providers consider ethnicity when assessing risk, it cannot be changed.

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Answer 3

Correct Answers:

Prophylactic

Rationale :

👉 Prophylactic surgery involves removing tissue or organs that have a high risk of developing cancer before cancer is actually present.

👉 The goal of prophylactic surgery is to reduce the likelihood of cancer developing in high-risk individuals.

👉 This type of surgery is often considered for clients with inherited genetic mutations that significantly increase cancer risk, such as:

BRCA1 or BRCA2 mutations associated with breast and ovarian cancer risk

Removal of high-risk tissues before malignant changes occur

👉 The procedure is performed as a preventive measure rather than as a treatment for an existing tumor.

👉 Clients considering prophylactic surgery require education about benefits, risks, alternatives, and psychological effects.

👉 Therefore, removing high-risk tissue before disease develops is classified as prophylactic surgery.

❌ Reconstructive

👉 Reconstructive surgery is performed to restore appearance, function, or body structure after injury, disease, or cancer treatment.

👉 It does not involve removing tissues to prevent cancer.

❌ Palliative

👉 Palliative surgery is performed to relieve symptoms and improve quality of life when a disease cannot be cured.

👉 It may reduce pain, obstruction, or discomfort but does not prevent cancer development.

❌ Diagnostic

👉 Diagnostic surgery is performed to obtain tissue samples or evaluate a suspected disease.

👉 Examples include biopsies used to determine whether cancer is present.

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Answer 4

Correct Answers:

Assess the client's oral cavity and mucous membranes for extent of lesions and signs of infection.

Rationale :

👉 The first nursing action is assessment before intervention. The nurse must determine the severity and cause of the mouth sores before selecting treatment.

👉 Chemotherapy can damage rapidly dividing cells in the oral mucosa, causing mucositis, which may lead to painful ulcers and difficulty eating or drinking.

👉 Assessing the oral cavity helps the nurse identify:

Location and severity of lesions

Bleeding

White patches indicating possible fungal infection

Redness, swelling, or drainage suggesting infection

👉 Chemotherapy can suppress the immune system, increasing the client’s risk for oral infections, especially fungal infections such as candidiasis.

👉 The assessment findings guide further interventions, including oral care measures, pain management, and possible medication therapy.

👉 Early recognition and management help prevent complications such as dehydration, malnutrition, and systemic infection.

👉 Therefore, the nurse should first assess the oral cavity and mucous membranes.

❌ Encourage the client to use a soft-bristled toothbrush and perform frequent oral rinses.

👉 This is an appropriate intervention for preventing and managing chemotherapy-induced mucositis.

👉 However, assessment must occur first to determine the extent of injury and whether infection is present.

❌ Notify the provider so a topical anesthetic or antifungal medication can be prescribed.

👉 Medications may be needed, but the nurse should first assess the oral lesions before notifying the provider.

👉 Treatment depends on whether the problem is mucositis, infection, or another oral complication.

❌ Offer the client carbonated beverages to soothe the oral mucosa.

👉 Carbonated beverages can irritate damaged oral tissues and may increase discomfort.

👉 Clients with mucositis should avoid irritating substances and use gentle oral care measures.

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Answer 5

Correct Answers:

Excessive IV fluid administration

Rationale :

👉 Bilateral crackles at the lung bases and pedal edema are classic signs of fluid volume excess (fluid overload).

👉 Excessive IV fluid administration can cause the body to retain more fluid than it can effectively circulate and eliminate.

👉 The excess fluid may move into the lungs, causing pulmonary congestion, which results in crackles heard during lung auscultation.

👉 Fluid can also accumulate in dependent areas of the body, especially the lower extremities, causing pedal edema.

👉 The nurse should monitor for additional signs of fluid overload, including:

Weight gain

Increased blood pressure

Shortness of breath

Jugular venous distention

Decreased oxygen saturation

👉 Early identification is important because severe fluid overload can progress to pulmonary edema and respiratory distress.

👉 Therefore, excessive IV fluid administration is the factor most likely contributing to these findings.

❌ Prolonged fever

👉 Prolonged fever commonly causes fluid loss through sweating and increased metabolic demands.

👉 It is more likely to contribute to dehydration rather than fluid overload with edema and crackles.

❌ Hyperventilation

👉 Hyperventilation causes increased respiratory rate and can lead to changes in carbon dioxide levels.

👉 It does not cause fluid accumulation in the lungs or peripheral edema.

❌ Fluid volume shifts secondary to vomiting

👉 Vomiting usually causes fluid volume deficit due to loss of fluids and electrolytes.

👉 It is more likely to cause dehydration, low blood pressure, and decreased urine output rather than crackles and edema.

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Answer 6

Correct Answers:

Instruct client in careful hand hygiene
Encourage client to use an electric razor
Avoid contact with people who have a known or recent infection

Rationale :

✅ Instruct client in careful hand hygiene

👉 Chemotherapy can cause bone marrow suppression, leading to decreased white blood cells and increased risk of infection.

👉 Proper hand hygiene is one of the most effective methods to reduce the transmission of microorganisms.

👉 The client should wash hands frequently, especially:

Before eating

After using the restroom

After touching potentially contaminated surfaces

👉 Visitors and healthcare workers should also perform hand hygiene to protect the immunocompromised client.

✅ Encourage client to use an electric razor

👉 Chemotherapy clients are at increased risk for infection because of possible neutropenia.

👉 An electric razor reduces the risk of cuts and skin injuries compared with a traditional razor.

👉 Breaks in the skin can provide an entry point for bacteria and increase infection risk.

✅ Avoid contact with people who have a known or recent infection

👉 Clients receiving chemotherapy have weakened immune defenses and may not be able to fight infections effectively.

👉 Avoiding individuals who are sick reduces exposure to infectious organisms.

👉 The client should avoid close contact with people who have illnesses such as colds, influenza, or other contagious infections.

❌ Continue to use the same water pitcher throughout hospital stay

👉 Using the same water pitcher without proper cleaning increases the risk of bacterial contamination.

👉 Immunocompromised clients require clean supplies and infection-control practices to reduce exposure to pathogens.

❌ Encourage intake of fresh fruits and vegetables

👉 Fresh fruits and vegetables may contain bacteria or fungi that can increase infection risk in clients who are severely immunocompromised.

👉 During periods of neutropenia, clients may need a modified diet with properly washed or cooked foods according to facility guidelines.

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Answer 7

Correct Answers:

"I will learn to manage these day-to-day changes over time."

Rationale :

👉 Chronic diseases are long-term conditions that often require ongoing management rather than complete recovery or cure.

👉 Clients with chronic illnesses must learn how to adapt to changes in their health status and incorporate treatments into their daily routines.

👉 Effective management may include:

Medication adherence

Lifestyle modifications

Symptom monitoring

Regular healthcare visits

Coping strategies

👉 This statement demonstrates realistic expectations and acceptance of the need for long-term self-management.

👉 Chronic disease management focuses on maintaining function, preventing complications, and improving quality of life.

👉 The nurse should support the client in developing coping skills and confidence in managing the condition.

👉 Therefore, the statement about learning to manage day-to-day changes indicates correct understanding.

❌ "I will recover completely with medication."

👉 Many chronic diseases cannot be completely cured with medication.

👉 Medications are often used to control symptoms, slow progression, and prevent complications rather than eliminate the disease.

❌ "If I follow this treatment plan I will recover quickly."

👉 Chronic illnesses typically require long-term management and do not usually resolve quickly.

👉 Following the treatment plan improves outcomes but does not guarantee rapid recovery.

❌ "This should only affect my physical health."

👉 Chronic diseases can affect multiple areas of life, including:

Emotional health

Social relationships

Financial concerns

Daily activities

👉 A holistic approach is needed to manage the impact of chronic illness.

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Answer 8

Correct Answers:

Loop diuretics

Rationale :

👉 Loop diuretics, such as furosemide, can cause ototoxicity, which may present as tinnitus (ringing in the ears).

👉 Ototoxic medications can damage the structures of the inner ear, affecting hearing and balance.

👉 Loop diuretics may cause hearing-related adverse effects, especially when:

Given in high doses

Administered rapidly by IV route

Combined with other ototoxic medications

👉 The nurse should monitor clients receiving loop diuretics for symptoms such as:

Tinnitus

Hearing changes

Dizziness or vertigo

👉 Early recognition of ototoxicity allows the healthcare provider to adjust treatment and prevent permanent hearing damage.

👉 Therefore, loop diuretics are the medication class most associated with tinnitus.

❌ Beta blockers

👉 Beta blockers commonly cause effects such as bradycardia, hypotension, and fatigue.

👉 They are not commonly associated with tinnitus or ototoxicity.

❌ ACE inhibitors

👉 ACE inhibitors may cause adverse effects such as cough, hyperkalemia, and angioedema.

👉 Tinnitus is not a typical adverse effect of this medication class.

❌ Anticholinergics

👉 Anticholinergic medications commonly cause dry mouth, urinary retention, constipation, and blurred vision.

👉 They are not commonly linked to tinnitus

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Answer 9

Correct Answers:

Start prescribed antibiotic eye drops

Rationale :

👉 Bacterial conjunctivitis is caused by bacterial infection of the conjunctiva and is commonly treated with prescribed antibiotic eye drops.

👉 The client’s findings of red, burning eyes and crusted eyelids are consistent with bacterial conjunctivitis, which often produces thick, purulent discharge that causes eyelids to stick together.

👉 Administering prescribed antibiotic drops helps eliminate the bacterial infection and reduces the duration of symptoms.

👉 Early treatment also decreases the risk of spreading the infection to the other eye or to other individuals.

👉 The nurse should ensure proper administration technique, including avoiding contact between the dropper tip and the eye.

👉 The nurse should continue monitoring for worsening symptoms, such as eye pain, vision changes, or increased swelling.

👉 Therefore, initiating the prescribed antibiotic eye drops is the appropriate action.

❌ Educate the client on hand hygiene and not sharing towels

👉 This teaching is important because bacterial conjunctivitis is contagious and can spread through contaminated hands or personal items.

👉 However, it is a preventive measure and does not address the active infection as the first treatment action.

❌ Obtain a swab for culture before administering drops

👉 Cultures are not routinely required for uncomplicated bacterial conjunctivitis.

👉 A culture may be obtained for severe, recurrent, or treatment-resistant infections, but routine cases are usually treated based on clinical findings.

❌ Apply warm compresses to the eyelids

👉 Warm compresses can provide comfort and help remove crusted discharge.

👉 However, they do not treat the underlying bacterial infection and are considered supportive care.

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Answer 10

Correct Answers:

Hypermagnesemia

Rationale :

👉 Clients with chronic kidney disease are at risk for hypermagnesemia because the kidneys are unable to effectively excrete excess magnesium.

👉 When kidney function declines, magnesium can accumulate in the bloodstream, causing elevated magnesium levels.

👉 Hypermagnesemia can cause neuromuscular symptoms, including:

Muscle weakness

Muscle cramping

Decreased deep tendon reflexes

Lethargy

Hypotension

Cardiac conduction abnormalities

👉 The client’s symptoms of severe muscle cramping and weakness are consistent with an electrolyte disturbance related to impaired renal clearance.

👉 The nurse should review magnesium levels, assess neurological status, and monitor cardiac function.

👉 Early recognition is important because severe hypermagnesemia can progress to respiratory depression and cardiac complications.

👉 Therefore, hypermagnesemia is the most likely electrolyte imbalance.

❌ Hyperphosphatemia

👉 Hyperphosphatemia is common in CKD because the kidneys cannot remove phosphate effectively.

👉 However, it is more associated with hypocalcemia, bone pain, and muscle spasms (tetany) rather than the primary finding of muscle weakness and cramping.

❌ Hyponatremia

👉 Hyponatremia may occur in CKD due to impaired water regulation.

👉 It commonly causes neurological symptoms such as confusion, headache, seizures, and altered mental status rather than severe muscle cramping.

❌ Hypernatremia

👉 Hypernatremia is associated with excessive sodium concentration and water loss.

👉 It commonly causes thirst, confusion, restlessness, and neurological changes rather than muscle weakness related to CKD.

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Ati Custom ASN Adult Health I NSG 2600 Exam 1

No.

1 :
A nurse is assessing a client's intravenous (IV) site and suspects infiltration. Which assessment finding best supports this suspicion?

2 :
A nurse is reviewing risk factors for chronic disease with a client. Which of the following is considered a modifiable risk factor?

3 :
Which type of surgery involves removing tissue or organs at high risk for developing cancer before any disease is present?

4 :
A client receiving chemotherapy reports the development of painful mouth sores. Which action should the nurse take first?

5 :
During a client assessment, the nurse notes bilateral crackles at the lung bases and pedal edema. Which of the following factors could have contributed to these findings?

6 :
A nurse is educating a client who is receiving chemotherapy about methods to decrease their risk of infection. Which of the following should be discussed with the client? (Select All that Apply.)

7 :
A nurse is reinforcing teaching for a client newly diagnosed with a chronic disease. Which client statement indicates an understanding of the diagnosis?

8 :
A nurse is reviewing a client's medication list after the client reports experiencing tinnitus. Which of the following medications could cause this condition?

9 :
A client presents with red, burning eyes and crusted eyelids. The RN suspects bacterial conjunctivitis. Which action should the nurse implement first?

10 :
A client with a past medical history of chronic kidney disease is admitted to the hospital. During assessment, the client complains of severe muscle cramping and muscle weakness. Which electrolyte imbalance should the nurse suspect?

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Ati Custom ASN Adult Health I NSG 2600 Exam 1

No.

1 : A nurse is assessing a client's intravenous (IV) site and suspects infiltration. Which assessment finding best supports this suspicion?

2 : A nurse is reviewing risk factors for chronic disease with a client. Which of the following is considered a modifiable risk factor?

3 : Which type of surgery involves removing tissue or organs at high risk for developing cancer before any disease is present?

4 : A client receiving chemotherapy reports the development of painful mouth sores. Which action should the nurse take first?

5 : During a client assessment, the nurse notes bilateral crackles at the lung bases and pedal edema. Which of the following factors could have contributed to these findings?

6 : A nurse is educating a client who is receiving chemotherapy about methods to decrease their risk of infection. Which of the following should be discussed with the client? (Select All that Apply.)

7 : A nurse is reinforcing teaching for a client newly diagnosed with a chronic disease. Which client statement indicates an understanding of the diagnosis?

8 : A nurse is reviewing a client's medication list after the client reports experiencing tinnitus. Which of the following medications could cause this condition?

9 : A client presents with red, burning eyes and crusted eyelids. The RN suspects bacterial conjunctivitis. Which action should the nurse implement first?

10 : A client with a past medical history of chronic kidney disease is admitted to the hospital. During assessment, the client complains of severe muscle cramping and muscle weakness. Which electrolyte imbalance should the nurse suspect?

1 :
A nurse is assessing a client's intravenous (IV) site and suspects infiltration. Which assessment finding best supports this suspicion?

2 :
A nurse is reviewing risk factors for chronic disease with a client. Which of the following is considered a modifiable risk factor?

3 :
Which type of surgery involves removing tissue or organs at high risk for developing cancer before any disease is present?

4 :
A client receiving chemotherapy reports the development of painful mouth sores. Which action should the nurse take first?

5 :
During a client assessment, the nurse notes bilateral crackles at the lung bases and pedal edema. Which of the following factors could have contributed to these findings?

6 :
A nurse is educating a client who is receiving chemotherapy about methods to decrease their risk of infection. Which of the following should be discussed with the client? (Select All that Apply.)

7 :
A nurse is reinforcing teaching for a client newly diagnosed with a chronic disease. Which client statement indicates an understanding of the diagnosis?

8 :
A nurse is reviewing a client's medication list after the client reports experiencing tinnitus. Which of the following medications could cause this condition?

9 :
A client presents with red, burning eyes and crusted eyelids. The RN suspects bacterial conjunctivitis. Which action should the nurse implement first?

10 :
A client with a past medical history of chronic kidney disease is admitted to the hospital. During assessment, the client complains of severe muscle cramping and muscle weakness. Which electrolyte imbalance should the nurse suspect?