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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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. "I should eat a snack before exercising." B. "I should skip a meal if my blood sugar is high." C. "I should increase my insulin dose if I am stressed." D. "I should drink alcohol only on special occasions."

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.

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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

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Correct Answer is A

Explanation

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