A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

Stop the infusion and remove the IV catheter.

Apply a warm compress to the infusion site.

Notify the provider and obtain an order for a different IV site.

Slow down the infusion rate and monitor the client.

Answer and Explanation

The Correct Answer is A

The nurse should stop the infusion and remove the IV catheter as soon as possible if phlebitis is suspected. Phlebitis is inflammation of a vein that can be caused by mechanical, chemical, or infectious factors. Potassium chloride is a vesicant medication that can cause severe tissue damage if it extravasates into the surrounding tissues.

The nurse should apply a warm compress to the infusion site after removing the IV catheter to reduce inflammation and discomfort. The nurse should notify the provider and obtain an order for a different IV site to continue the infusion of potassium chloride at a different location. The nurse should not slow down the infusion rate and monitor the client because this could worsen the condition and increase the risk of complications.

b) Incorrect. This is an appropriate action after removing the IV catheter, but not before.

c) Incorrect. This is an appropriate action after removing the IV catheter and applying a warm compress, but not before.

d) Incorrect. This is not an appropriate action because it could worsen the condition and increase the risk of complications.

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Correct Answer is A

Explanation

Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors and increases the risk of bleeding. The client should use a soft-bristled toothbrush and an electric razor to prevent trauma and bleeding from minor cuts or abrasions.

A) Correct. This statement indicates that the client understands how to prevent bleeding while taking warfarin.

B) This statement indicates a lack of understanding of the teaching. The client should avoid sudden changes in vitamin K intake, as this can affect the therapeutic level of warfarin and increase the risk of clotting or bleeding. Green leafy vegetables are high in vitamin K and should be consumed in consistent amounts.

C) This statement indicates a lack of understanding of the teaching. The client should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen while taking warfarin, as they can increase the risk of bleeding. The client should consult with the provider before taking any over-the-counter medications for pain relief.

D) This statement indicates a lack of understanding of the teaching. Warfarin does not affect blood pressure directly but rather affects blood clotting. The client should monitor their international normalized ratio (INR), which measures the effectiveness of warfarin, regularly while taking this medication.

A. Check the client's identification band. B. Explain the purpose and side effects of the medication. C. Compare the medication label with the medication administration record (MAR). D. Assess the client for contraindications and allergies.

Correct Answer is C

Explanation

The nurse should follow the six rights of medication administration, which include the right client, right medication, right dose, right route, right time, and right documentation. The first action the nurse should take is to compare the medication label with the MAR to ensure that they match and that the medication has been prescribed for the client.

A) This is an important action, but not the first one. The nurse should check the client's identification band after comparing the medication label with the MAR and before administering the medication.

B) This is an important action, but not the first one. The nurse should explain the purpose and side effects of the medication after comparing the medication label with the MAR and before administering the medication.

C) Correct. This is the first action the nurse should take to ensure that the right medication is being given to the right client.

D) This is an important action, but not the first one. The nurse should assess the client for contraindications and allergies after comparing the medication label with the MAR and before administering the medication.

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A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for warfarin about safe medication practices. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take to ensure medication safety? (Select all that apply.)