A nurse is caring for a client who has a prescription for a peripheral IV catheter.

After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

• Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
• Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

• Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
• Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

• Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
• Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

• Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
• Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

The correct answer is choice A, hematuria.

Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood.

Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.

Choice B, polyuria, is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.

Choice C, weight loss, is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.

Choice D, hypotension, is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.

Normal ranges for blood pressure are less than 120/80 mmHg for adults.

Normal ranges for urine output are about 800 to 2000 mL per day for adults.

Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.