A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)

Discontinue the IV line and start a new one in another site.

Apply a warm compress to the IV site.

Elevate the affected extremity on a pillow.

Administer an antihistamine to the client.

Flush the IV line with normal saline.

Answer and Explanation

Correct Answer : A,B,C

A) Correct. The nurse should discontinue the IV line and start a new one in another site. The IV site is showing signs of phlebitis, which is inflammation of the vein caused by mechanical, chemical, or bacterial irritation. Phlebitis can lead to complications such as thrombophlebitis, infection, or extravasation.

B) Correct. The nurse should apply a warm compress to the IV site to promote vasodilation and blood flow, which can help reduce inflammation and pain.

C) Correct. The nurse should elevate the affected extremity on a pillow to facilitate venous return and decrease edema.

D) Incorrect. The nurse should not administer an antihistamine to the client unless prescribed by the health care provider. Antihistamines are used to treat allergic reactions, not phlebitis.

E) Incorrect. The nurse should not flush the IV line with normal saline. Flushing the IV line can worsen the inflammation and increase the risk of infection or thrombus formation.

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Correct Answer is ["A","B","C","D"]

Explanation

A) Correct. The nurse should include reducing sodium intake to less than 2 g per day in the teaching. Sodium can increase fluid retention and blood volume, which can raise blood pressure.

B) Correct. The nurse should include increasing physical activity to at least 30 minutes per day in the teaching. Physical activity can lower blood pressure by strengthening the heart, improving blood circulation, and reducing body weight.

C) Correct. Limiting alcohol consumption to no more than two drinks per day for men and one drink per day for women. Excessive alcohol consumption can raise blood pressure, so moderation is important.

D) Correct. Quitting smoking and avoiding exposure to secondhand smoke. Smoking and exposure to secondhand smoke are significant risk factors for hypertension and other cardiovascular diseases.

E) Incorrect. Taking a nap for 20 minutes every afternoon. While rest and relaxation are important for overall well-being, taking a nap specifically for 20 minutes every afternoon may not be directly related to lowering blood pressure. It's better to focus on the other lifestyle modifications mentioned above.

A. The client shakes the inhaler well before use. B. The client holds their breath for 5 seconds after inhaling. C. The client exhales fully before placing the mouthpiece in their mouth. D. The client repeats the puff after 15 seconds if needed.

Correct Answer is A

Explanation

A) Correct. The client should shake the inhaler well before use to mix the medication and propellant evenly and ensure proper dosage delivery.

B) Incorrect. The client should hold their breath for 10 seconds after inhaling to allow the medication to reach the lower airways and improve bronchodilation.

C) Incorrect. The client should exhale fully after placing the mouthpiece in their mouth and closing their lips around it. This can prevent wasting of medication and ensure optimal inhalation.

D) Incorrect. The client should repeat the puff after 1 minute if needed or prescribed. Waiting for 1 minute between puffs can allow enough time for the first puff to take effect and reduce adverse effects such as tachycardia or tremors.

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A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)

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A nurse is caring for a client who is receiving intravenous (IV) antibiotics for a severe infection. The nurse observes that the IV site is red, swollen, and painful. Which of the following actions should the nurse take? (Select all that apply.)