A nurse is caring for a client with dementia who frequently tries to get out of bed. Which of the following actions should the nurse take?

Choice A rationale

Initiating a new IV line below an infected site increases the risk of further infection because fluids can carry pathogens downstream into the vascular system, exacerbating inflammation and infection.

Choice B rationale

Discontinuing the infusion immediately halts further irritation and provides an opportunity to evaluate and address the underlying cause, such as phlebitis or infiltration, to prevent complications like infection or thrombophlebitis.

Choice C rationale

Raising the head of the bed has no direct effect on managing localized inflammation or infection at the IV site and does not address the underlying pathology, such as phlebitis or infiltration.

Choice D rationale

Obtaining a culture from the insertion site is unnecessary unless systemic signs of infection, like fever or sepsis, are present; local management is prioritized first to resolve the issue effectively.

Choice A rationale

Reporting elevated blood pressure is important; however, verifying the accuracy of the reading ensures reliable data before initiating any interventions or contacting the provider.

Choice B rationale

While baseline comparison is essential, rechecking ensures accuracy and rules out any transient factors or equipment errors causing the abnormal blood pressure reading.

Choice C rationale

Administering antihypertensives without confirming the abnormal reading may lead to potential hypotension or overtreatment if the initial measurement was inaccurate.

Choice D rationale

Rechecking the blood pressure confirms accuracy, rules out transient elevations or equipment issues, and provides reliable data for appropriate clinical decision-making and subsequent actions.