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. Provide support by holding the client's arm:
While providing support is essential, holding the client's arm may not prevent a fall. It's better to focus on a controlled descent to the floor.
B. Maintain a narrow base of support:
Maintaining a narrow base of support is not advisable when a client is falling. A wider base of support provides more stability.
C. Lower the client to the floor:
This is the correct action. When a client begins to fall, the nurse should lower them to the floor in a controlled manner to minimize the risk of injury.
D. Lean the client toward the wall:
Leaning the client toward the wall may not provide sufficient support during a fall. The goal is to lower the client to the floor in a way that minimizes the risk of injury.
Correct Answer is B
Explanation
A. Concurrent treatment for GERD:
This is not typically a contraindication for hormone replacement therapy (HRT). GERD treatment is not directly related to the decision to use HRT.
B. History of breast cancer:
This is a contraindication for HRT. Estrogen replacement therapy has been associated with an increased risk of breast cancer. Therefore, individuals with a history of breast cancer are generally advised against using HRT.
C. History of dermatitis:
A history of dermatitis is not a contraindication for HRT. However, the decision to use HRT should be made based on a comprehensive assessment of the client's overall health and risk factors.
D. Multiple hospitalizations for COPD:
While COPD itself is not a contraindication for HRT, decisions about HRT should consider the individual's overall health status and potential risks. Factors such as smoking history and respiratory function may be considered in the assessment.
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