A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
Discontinue the existing IV infusion.
Insert an IV catheter in the opposite extremity.
Apply warm, moist compresses to the site.
Elevate the extremity.
The Correct Answer is A
A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.
B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.
C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.
D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A 15-year-old client who has acne:
Acne alone is not a contraindication to oral contraceptives. In fact, oral contraceptives can sometimes be prescribed to help manage acne.
B. A client who has a menstrual cycle every 14 days:
Having a menstrual cycle every 14 days may indicate an irregular cycle, but it's not a direct contraindication to oral contraceptives. However, the cause of the frequent cycles might need evaluation before starting oral contraceptives.
C. A client who has a blood pressure of 140/90 mm Hg:
Elevated blood pressure (140/90 mm Hg or higher) is a contraindication to oral contraceptives. It increases the risk of complications such as stroke, heart attack, or other cardiovascular issues.
D. A client who has a hematocrit of 39%:
A hematocrit level of 39% is within the normal range and is not a contraindication to oral contraceptives.
Correct Answer is C
Explanation
A. "I'm sure your wife will begin to feel better soon."
This response is somewhat reassuring but may come across as dismissive or overly optimistic. It doesn't acknowledge the partner's feelings or offer support.
B. "It must be very difficult for you to see your wife in pain."
This response acknowledges the partner's emotions and shows empathy. While it recognizes the difficulty the partner is experiencing, it doesn't directly address the partner's desire to do something to help the wife.
C. "I wish there was more that I could do to relieve your wife's pain, too."
This response directly empathizes with the partner's wish to help the wife, expressing a shared concern. It conveys a sense of teamwork between the nurse and the partner, fostering a supportive connection.
D. "We're doing everything we can to keep your wife comfortable."
This response provides information about the actions being taken by the medical team but may not directly address the partner's expressed desire to contribute or alleviate the wife's pain.
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