A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?

Initiate a new IV line below the original insertion site.

Discontinue the infusion.

Raise the head of the bed.

Obtain a culture from the area of the insertion site.

Answer and Explanation

The Correct Answer is B

A. Initiate a new IV line below the original insertion site. – If phlebitis or infection is present, a new IV should be placed in another limb or at a site above the previous insertion, not below.

B. Discontinue the infusion. – The first step in treating suspected phlebitis or IV infiltration is stopping the infusion to prevent further tissue damage.

C. Raise the head of the bed. – Elevating the head of the bed is not relevant in managing IV site complications.

D. Obtain a culture from the area of the insertion site. – Cultures are not necessary unless infection is suspected and prescribed by a provider.

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Correct Answer is C

Explanation

A. Administer antibiotic therapy to the client. This is a priority intervention, but it is not the first action. Before administration, infection control measures should be in place.

B. Provide the client with analgesics as needed. Pain management is important but is not the first priority. The spread of infection must be controlled immediately.

C. Initiate droplet precautions for the client. Meningococcal meningitis is highly contagious. Droplet precautions (mask, private room) must be initiated immediately to prevent transmission before other interventions.

D. Educate the client about the meningococcal vaccine. Vaccination is a preventive measure but does not address the immediate risk of infection spread.

A. Pull the fire alarm. B. Close the fire doors. C. Evacuate the room. D. Extinguish the fire.

Correct Answer is C

Explanation

A. Pull the fire alarm. While activating the alarm is crucial, the immediate priority is client safety, meaning evacuation comes first.

B. Close the fire doors. Closing doors helps contain the fire, but ensuring client safety is the priority.

C. Evacuate the room. According to the RACE (Rescue, Alarm, Contain, Extinguish) protocol, the first step is to Rescue clients in immediate danger, then pull the alarm.

D. Extinguish the fire. Attempting to put out the fire is only appropriate if the fire is small and manageable. If the fire is significant, evacuating clients takes precedence.

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