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 use an electric razor when shaving to reduce the risk of bleeding from minor cuts or nicks. Warfarin is an anticoagulant that inhibits blood clotting and increases the bleeding time.
B) Incorrect. The client should not eat more green leafy vegetables to prevent bleeding. Green leafy vegetables are high in vitamin K, which antagonizes the effect of warfarin and reduces its anticoagulant activity.
C) Incorrect. The client should not take an extra dose if they miss one. Taking an extra dose can cause excessive anticoagulation and increase the risk of bleeding or hemorrhage.
D) Incorrect. The client should not check their blood pressure every day unless instructed by their health care provider. Checking blood pressure every day is not related to warfarin therapy and may cause unnecessary anxiety or confusion.
Correct Answer is D
Explanation
A) Incorrect. The nurse should instruct the client to store unopened insulin vials in the refrigerator, not in the freezer. Freezing can damage the insulin and make it ineffective.
B) Correct. The nurse should instruct the client to rotate injection sites within the same anatomical region, such as the abdomen, thighs, arms, or buttocks. Rotating injection sites can prevent lipodystrophy, which is a disorder of fat metabolism that causes hypertrophy or atrophy of subcutaneous tissue.
C) Incorrect. The nurse should instruct the client not to mix short-acting and long-acting insulins in the same syringe. Mixing different types of insulins can alter their onset, peak, and duration of action and affect blood glucose control.
D) Correct. The nurse should instruct the client to draw up regular insulin before NPH insulin when mixing them in the same syringe. This can prevent contamination of the regular insulin vial with NPH insulin, which can affect its potency and clarity.
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