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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This is correct as eating a snack before exercising can help to prevent hypoglycemia by providing glucose for energy and preventing a sudden drop in blood sugar levels.
B) This is incorrect as skipping a meal can cause hypoglycemia by depriving the body of glucose and creating an imbalance between insulin and glucose levels. Clients taking insulin should eat regular meals and snacks and monitor their blood sugar levels frequently.
C) This is incorrect as increasing the insulin dose without consulting with the provider can cause hypoglycemia by lowering the blood sugar levels too much. Stress can affect blood sugar levels in different ways depending on the type and duration of stress and the individual's response. Clients taking insulin should consult with their provider about how to adjust their insulin dose according to their stress level and blood sugar readings.
D) This is incorrect as drinking alcohol can cause hypoglycemia by inhibiting the liver's production of glucose and increasing the risk of insulin overdose. Clients taking insulin should avoid or limit alcohol intake and never drink alcohol on an empty stomach.
Correct Answer is B
Explanation
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.
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