The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

Discontinue the intravenous line

Complete an incident report

Start a new IV in the right hand

Place a warm compress over the site

The correct answer is A.

Answer and Explanation

The Correct Answer is A

A. Discontinue the intravenous line: The presence of tenderness and a red streak suggests phlebitis or possibly an early sign of infection. The first and most important step is to discontinue the IV line to prevent further irritation or infection.
B. Complete an incident report: While documentation is important, it is not the first action to take. Immediate attention should be given to the client’s physical condition before completing any paperwork.
C. Start a new IV in the right hand: While starting a new IV is necessary for continued therapy, the first action should be to remove the current IV line to prevent further complications. Starting a new IV can be done immediately afterward.
D. Place a warm compress over the site: A warm compress can help alleviate pain and reduce inflammation, but the priority action is to discontinue the IV line to stop further damage or infection.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Steak and scrambled eggs: Steak and scrambled eggs are excellent sources of heme iron, which is highly bioavailable and easily absorbed by the body. This choice reflects a good understanding of dietary sources rich in iron.
B. Cornmeal muffin and orange juice: While orange juice can enhance iron absorption due to its vitamin C content, cornmeal muffins are not a significant source of iron. This option does not indicate a strong understanding of iron-rich foods.
C. Cantaloupe and cottage cheese: Both cantaloupe and cottage cheese are low in iron content. This menu choice does not reflect an understanding of the best dietary sources of iron.
D. Strawberry pancakes and coffee: Strawberries have some iron, but not in significant amounts, and coffee can inhibit iron absorption due to its polyphenol content. This choice does not indicate an understanding of iron-rich foods.

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr B. Elevate the feet and lower the head C. Call the surgeon and report the vital signs D. Monitor the vital signs every 15 minutes

Correct Answer is B

Explanation

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

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The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which menu choice indicates that a client understands their nurse's teaching about the best dietary sources of iron?

Correct Answer is A

Explanation

The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Correct Answer is B

Explanation

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