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
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.
Correct Answer is B
Explanation
A) Incorrect. The nurse should not instruct the client to stop taking both medications immediately without consulting the client's primary care provider. Abruptly discontinuing some medications can cause adverse effects or withdrawal symptoms.
B) Correct. The nurse should assess the client for signs of gastrointestinal bleeding, such as abdominal pain, black or tarry stools, or coffee-ground emesis. Ibuprofen and naproxen are both nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of gastrointestinal bleeding when taken together or for a long time.
C) Incorrect. The nurse should document the finding in the client's medical record after assessing the client and notifying the primary care provider. Documentation is an important but not a priority action in this situation.
D) Incorrect. The nurse should notify the client's primary care provider after assessing the client for signs of gastrointestinal bleeding. The primary care provider may need to adjust or change the client's medication regimen to prevent further complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.