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 D
Explanation
A. Aspirin is not primarily prescribed to prevent fever. Its primary mechanism of action is related to its effects on platelets and blood clotting rather than its antipyretic (fever-reducing) properties.
B. While aspirin can provide analgesic (pain-relieving) effects, especially for mild to moderate pain, its use in clients with coronary artery disease is primarily due to its antiplatelet properties rather than its analgesic effects.
C. Aspirin has some anti-inflammatory properties, but in the context of coronary artery disease, its main benefit is related to its antiplatelet function rather than its anti-inflammatory effects.
D. Aspirin is widely prescribed in cardiovascular conditions like coronary artery disease because it inhibits the aggregation of platelets, reducing the risk of blood clot formation. This antiplatelet effect helps in preventing blood clots that could potentially lead to further blockages in the arteries, reducing the risk of complications such as heart attacks or strokes in individuals with heart disease.
Correct Answer is D
Explanation
A. Coolness at the IV insertion site is not a typical sign of phlebitis. Phlebitis often presents with warmth or increased heat around the vein due to inflammation.
B. Drainage at the IV site might indicate infection or other complications but is not a specific sign of phlebitis. Phlebitis primarily manifests as redness, tenderness, and swelling along the vein.
C. Pallor (pale coloration) at the IV site is not a typical sign of phlebitis. Phlebitis usually presents with redness or erythema due to inflammation.
D. Erythema (redness) at the IV catheter insertion site is a hallmark sign of phlebitis. It indicates inflammation of the vein where the catheter is placed and is a common early sign of phlebitis. Other signs include warmth, tenderness, and swelling along the vein.
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