Student Success Starts Here

A client's peripheral IV site is red, warm, and tender, with a palpable cord along the vein. What should the nurse do first?

1. Slow the infusion rate and reassess in one hour
2. Discontinue the IV and restart it in another site
3. Apply a cold compress over the site
4. Flush the line with normal saline

Answer: B. These are signs of phlebitis. The IV must be discontinued and restarted elsewhere. Slowing, flushing, or compressing while the catheter stays in place does not remove the source of irritation.

The nurse receives report on four clients. Which client should be assessed first?

1. A client with asthma who has increasing shortness of breath and is using accessory muscles
2. A client requesting pain medication before physical therapy
3. A client scheduled for discharge teaching this morning
4. A client with a dressing change due in 30 minutes

Answer: A. Airway and breathing come first (ABCs). Increasing work of breathing signals potential respiratory compromise and must be assessed before routine needs.

While scanning a medication, the barcode system alerts that the dose does not match the order. The medication label appears correct. What should the nurse do?

1. Administer the medication since the label looks correct
2. Override the alert and document the discrepancy afterward
3. Hold the medication and verify the order and dose before giving anything
4. Ask the client whether this is the pill they usually take

Answer: C. Never bypass a safety alert. Verify the order, dose, and product with the pharmacy or provider before administration, the rights of medication administration protect the patient.

When calling a provider using SBAR, which information belongs in the "B"?

1. The client's current vital signs and your immediate concern
2. The client's admitting diagnosis, relevant history, and recent treatments
3. Your recommendation for what the provider should order
4. Your name, unit, and the client you are calling about

Answer: B. SBAR = Situation, Background, Assessment, Recommendation. Background covers diagnosis, pertinent history, and the clinical context leading up to the call.

Which action best prevents the spread of infection when providing wound care?

1. Wearing gloves eliminates the need for hand hygiene
2. Performing hand hygiene before applying and after removing gloves
3. Reusing gloves between tasks for the same client
4. Applying hand sanitizer over gloved hands between steps

Answer: B. Gloves are not a substitute for hand hygiene. Hands must be cleaned before donning and after doffing gloves, because contamination occurs during removal.