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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Correct Answer is C

Explanation

A. Vomiting: Vomiting is a common symptom associated with metabolic acidosis but is not a compensatory mechanism. It can lead to further electrolyte imbalances and dehydration.
B. Tachycardia: Tachycardia can occur as a response to acidosis but is not a direct compensatory mechanism for metabolic acidosis.
C. Deep rapid breathing: This is the correct choice. Deep rapid breathing, or Kussmaul respirations, is a compensatory mechanism for metabolic acidosis. It helps to expel carbon dioxide, thereby reducing acidity in the blood.
D. Watery diarrhea: Diarrhea can contribute to electrolyte imbalances and may exacerbate acidosis but is not a compensatory response by the body.

A. Weakness in upper extremities B. Headache C. Increased respiratory rate D. Blurred vision

Correct Answer is B

Explanation

A. Weakness in upper extremities: Spinal anesthesia generally affects the lower body, so weakness in the upper extremities is not typically related to this type of anesthesia.
B. Headache: This is the correct choice. A headache is a common post-operative complaint related to spinal anesthesia, often caused by a spinal fluid leak, leading to a post-dural puncture headache.
C. Increased respiratory rate: Spinal anesthesia typically does not affect respiratory rate significantly; it mainly impacts sensation and motor function below the level of anesthesia.
D. Blurred vision: This is not a common issue directly related to spinal anesthesia. Visual disturbances are not typical post-operative complaints associated with spinal anesthesia.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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