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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A) Correct. Medication reconciliation is a process that helps prevent medication errors by ensuring that the client receives the correct medications at the correct doses and times.
B) Correct. Medication reconciliation involves comparing the client's current medications with their previous ones to identify any discrepancies or changes.
C) Correct. Medication reconciliation should be done at every transition of care, such as admission, transfer, or discharge, to ensure continuity and safety of medication therapy.
D) Correct. Medication reconciliation requires the client to keep an updated list of all their medications, including prescription, over-the-counter, herbal, and dietary supplements, and to share it with their health care providers.
E) Incorrect. Medication reconciliation does not allow the client to adjust their medication doses as needed. The client should always follow the prescribed instructions and consult their health care provider before making any changes.
Correct Answer is ["A","B","C"]
Explanation
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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