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 A

Explanation

A. Ask the client to describe their feelings. Encouraging the client to express their emotions allows the nurse to assess their concerns and provide appropriate support. This is a key principle of therapeutic communication.

B. Discuss the competency of the surgeon with the client. While the surgeon's competency may help reassure the client, the nurse should not comment on the surgeon’s skill. Instead, the nurse should focus on the client's emotions and provide factual information about the procedure if needed.

C. Inform the client that others have had the procedure without problems. This response dismisses the client’s concerns rather than addressing their feelings. Each client’s experience is unique, and reassurance should be based on listening and providing accurate information.

D. Ask the client why they are experiencing anxiety. Asking “why” can make the client feel defensive. Instead, the nurse should use open-ended questions, such as "Can you tell me more about your concerns?", which encourages discussion without judgment.

A. Place the client on their side with their head forward. B. Administer an anticonvulsant medication. C. Time the length of the client's seizure. D. Loosen the client's gown and allow them to move freely.

Correct Answer is A

Explanation

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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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?

Nursing Test Bank

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