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.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A) This is correct as the INR level measures how long it takes for blood to clot and is used to monitor the effectiveness and safety of warfarin therapy. A high INR level indicates a higher risk of bleeding.

B) This is correct as some herbal supplements, such as garlic, ginger, ginkgo, and ginseng, can interact with warfarin and increase the risk of bleeding.

C) This is incorrect as vitamin K-rich foods, such as green leafy vegetables, can interfere with warfarin and decrease its effectiveness, leading to a lower risk of bleeding. However, clients taking warfarin should maintain a consistent intake of vitamin K-rich foods and avoid sudden changes in their diet.

D) This is correct as peptic ulcer disease is a condition that causes erosion and inflammation of the lining of the stomach or duodenum and can lead to bleeding complications, especially when taking warfarin.

E) This is incorrect as blood pressure does not directly affect the risk of bleeding from warfarin therapy. However, clients taking warfarin should monitor their blood pressure regularly and report any signs of hypertension or hypotension to their provider.

A. Crush or dissolve tablets and capsules before giving them to the client. B. Mix medications with food or liquids that are easy to swallow. C. Give one medication at a time and allow time for swallowing. D. Encourage the client to drink water before and after taking medications. E. Assess the client's mouth for pocketing of medications.

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

Explanation

B) This is correct as mixing medications with food or liquids that are easy to swallow can help to prevent choking and aspiration and improve compliance. However, some medications may interact with certain foods or liquids, so the nurse should check with the pharmacist before mixing them.

C) This is correct as giving one medication at a time and allowing time for swallowing can help to prevent choking and aspiration and ensure that each medication is taken correctly. The nurse should also monitor the client for signs of difficulty swallowing, such as coughing, gagging, drooling, or regurgitation.

E) This is correct as assessing the client's mouth for pocketing of medications can help to prevent medication errors and ensure that each medication is taken correctly. Pocketing of medications occurs when the client holds medications in their cheeks or under their tongue instead of swallowing them. This can lead to ineffective therapy, toxicity, or adverse effects.

A) This is incorrect as crushing or dissolving tablets and capsules before giving them to the client can alter their effectiveness, absorption, or bioavailability and cause medication errors or adverse effects. Some tablets and capsules are designed to be swallowed whole, such as enteric-coated, extended-release, or sublingual formulations. The nurse should check with the pharmacist before crushing or dissolving any tablets or capsules.

D) This is incorrect as encouraging the client to drink water before and after taking medications can help to prevent choking and aspiration and ensure adequate hydration, but it may not be appropriate for some clients who have dysphagia or who are on fluid restrictions. The nurse should assess the client's ability to drink water safely and follow their individualized plan of care.

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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 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.)

Correct Answer is ["A","B","D"]

Explanation

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.)

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

Explanation

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