A nurse is caring for a client who is receiving intravenous (IV) fluids. The nurse notices that the IV site is red, swollen, and painful. Which of the following actions should the nurse take first?

Apply a warm compress to the IV site.

Discontinue the IV infusion and remove the catheter.

Elevate the affected arm above the level of the heart.

Notify the provider and document the findings.

Answer and Explanation

The Correct Answer is B

B) This is correct as discontinuing the IV infusion and removing the catheter is the first action that the nurse should take when suspecting an IV site infection or phlebitis. This helps to prevent further complications and damage to the vein.

A) This is incorrect as applying a warm compress to the IV site can help to reduce inflammation and discomfort, but it is not the first action that the nurse should take. The nurse should apply a warm compress after discontinuing the IV infusion and removing the catheter.

C) This is incorrect as elevating the affected arm above the level of the heart can help to reduce swelling and improve blood flow, but it is not the first action that the nurse should take. The nurse should elevate the affected arm after discontinuing the IV infusion and removing the catheter.

D) This is incorrect as notifying the provider and documenting the findings are important steps in managing an IV site infection or phlebitis, but they are not the first actions that the nurse should take. The nurse should notify the provider and document the findings after discontinuing the IV infusion and removing the catheter.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["D","E"]

Explanation

Checking the medication label for any latex components and asking the client about any previous reactions to latex products are important precautions that can help prevent an allergic reaction. Some medications may contain latex in their packaging or formulation, and some clients may have more severe reactions than others.

A, B, and C are incorrect. Using a latex-free syringe and needle, wearing non-latex gloves, and applying a non-latex bandage are not precautions, but rather standard practices for administering an intramuscular injection to any client.

A. Check the medication label against the medication administration record (MAR) three times. B. Use two client identifiers before giving the medication. C. Ask the client to state their name and date of birth before giving the medication. D. Document the medication administration after completing other tasks. E. Follow the six rights of medication administration.

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

Explanation

A) This is correct as checking the medication label against the MAR three times is one of the six rights of medication administration and helps to ensure accuracy and safety.

B) This is correct as using two client identifiers is another one of the six rights of medication administration and helps to verify the identity of the client.

C) This is correct as asking the client to state their name and date of birth is another way of verifying the identity of the client and can also help to engage them in their care.

D) This is incorrect as documenting the medication administration should be done as soon as possible after giving the medication to avoid errors and omissions.

E) This is correct as following the six rights of medication administration (right client, right medication, right dose, right route, right time, right documentation) is a standard practice that helps to prevent medication errors.

View Question and Answer

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

A nurse is caring for a client who is receiving intravenous (IV) fluids. The nurse notices that the IV site is red, swollen, and painful. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering an intramuscular injection to a client who has a latex allergy. Which of the following precautions should the nurse take to prevent an allergic reaction? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A nurse is preparing to administer medication to a client who has a history of medication errors. Which of the following actions should the nurse take to prevent medication errors? (Select all that apply.)

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

Explanation

A nurse is teaching a client who has diabetes mellitus about how to prevent hypoglycemia when taking insulin. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is administering medication to a client who has dysphagia, or difficulty swallowing. Which of the following strategies should the nurse use to prevent medication errors and ensure safety? (Select all that apply.)

A nurse is caring for a client who is receiving intravenous (IV) fluids. The nurse notices that the IV site is red, swollen, and painful. Which of the following actions should the nurse take first?

A nurse is reviewing the medication administration record of a client who is receiving digoxin, a cardiac glycoside. The nurse notes that the client's apical pulse is 58 beats per minute. Which of the following actions should the nurse take?

A nurse is reviewing a client's medication list and notices that the client is taking warfarin, a blood thinner. Which of the following factors should the nurse assess as potential risk factors for bleeding? (Select all that apply.)