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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.

C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.

A. Client understands the surgical procedure B. Voluntary consent is given C. Client's ability to read the consent form D. Client's ability to pay for the consented surgical procedure E. Disclosure of the treatment is provided

Correct Answer is ["A","B","E"]

Explanation

A. Client understands the surgical procedure:

The client should have a clear understanding of the proposed surgical procedure, its risks, benefits, alternatives, and potential complications.

B. Voluntary consent is given:

The client's consent should be given voluntarily, without coercion or pressure from healthcare providers or others.

C. Client's ability to read the consent form:

While it is helpful for clients to be able to read the consent form, the ability to read the form is not a requirement for valid consent. The information should be explained verbally if the client cannot read.

D. Client's ability to pay for the consented surgical procedure:

The client's ability to pay for the procedure is not a factor in obtaining informed consent. Financial considerations do not affect the validity of the consent.

E. Disclosure of the treatment is provided:

Healthcare providers must disclose information about the proposed treatment, including its nature, purpose, risks, benefits, and potential alternatives, allowing the client to make an informed decision.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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