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. Request a dietary consult:

While dietary concerns may be addressed, checking vital signs is the priority when a client reports nausea, especially in the context of medication administration.

B. Check the client's vital signs:

This is the correct action. Nausea can be a symptom of digoxin toxicity. Checking vital signs, especially assessing for changes in heart rate, is crucial in determining whether the client is experiencing adverse effects of digoxin.

C. Request an order for an antiemetic:

Administering an antiemetic may be considered later, but the first priority is to assess the client's vital signs and determine if the nausea is related to digoxin toxicity.

D. Suggest that the client rests before eating the meal:

Resting before eating may be helpful for nausea, but the priority is to assess the client's vital signs and determine the cause of the nausea, especially in the context of digoxin use.

A. Place the child in prone position. B. Restrain the child. C. Place a tongue depressor in the child's mouth. D. Clear the area of hard objects. E. Loosen restrictive clothing.

Correct Answer is ["D","E"]

Explanation

A. Place the child in prone position:

Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.

B. Restrain the child:

Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.

C. Place a tongue depressor in the child's mouth:

It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.

D. Clear the area of hard objects:

Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.

E. Loosen restrictive clothing:

Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.

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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 caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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