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 ["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. 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 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 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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