Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
0100:Client's skin warm to touch. Crackles auscultated in lower lung lobes bilaterally. Mucous membranes show color expected for client's skin tone and dry. Client reports productive cough with yellow sputum
Pedal pulses 2+
Client reports mild penicillin allergy.
A nurse is assisting with the care of a client who has pneumonia.
A nurse is assisting with the care of a client who has pneumonia. For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Correct answer
B,C,F
Rationale
Apply cool compress to the extremity: A cool compress helps reduce pain and swelling associated with IV infiltration. Elevate extremity: Elevation promotes venous return and reduces edema. Send the catheter tip for culture: Given the client's edema, pain, and potential IV infiltration, infection is a concern.