The nurse is caring for a patient with an IV infusion in his left arm that was started 2 hours ago in the emergency department (ED) The patient complains of pain at the IV site and rates it as an 8 on a scale of 0 to 10. The nurse assesses the site and notes edema, erythema, and coolness to touch around the insertion site. What is the most appropriate action by the nurse?

Apply warm compresses to the site and elevate the arm.

Slow down the infusion rate and document the findings.

Stop the infusion, remove the IV catheter, and start a new IV in another site.

Notify the physician and obtain an order for an antihistamine.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Applying warm compresses to the site and elevating the arm may help to reduce pain and swelling, but they do not address the underlying cause of the problem, which is likely infiltration or phlebitis of the IV site. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing edema, coolness, and pallor. Phlebitis occurs when the vein becomes inflamed, causing pain, erythema, and warmth. Both conditions require immediate removal of the IV catheter and restarting a new IV in another site.

Choice B reason:

Slowing down the infusion rate and documenting the findings may be appropriate actions after removing the IV catheter and starting a new IV in another site, but they are not sufficient to resolve the problem. Slowing down the infusion rate may reduce the discomfort and prevent further complications, but it does not stop the leakage or inflammation of the IV site. Documenting the findings is important for legal and quality improvement purposes, but it does not provide any intervention for the patient's pain or risk of infection.

Choice C reason:

Stopping the infusion, removing the IV catheter, and starting a new IV in another site is the most appropriate action by the nurse. This action prevents further damage to the tissue or vein, reduces the risk of infection, and restores adequate IV access for fluid and medication administration. The nurse should also apply a sterile dressing to the affected site, monitor for signs of infection or complications, and notify the physician if needed. This is the correct answer.

Choice D reason:

Notifying the physician and obtaining an order for an antihistamine is not an appropriate action by the nurse. This action implies that the patient is having an allergic reaction to the IV fluid or medication, which is not supported by the assessment findings. An antihistamine may help to reduce itching or swelling, but it does not address the cause of the pain or prevent further tissue or vein damage. The nurse should notify the physician after removing the IV catheter and starting a new IV in another site, and only if there are signs of infection or complications that require medical intervention.

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Correct Answer is A

Explanation

Choice A reason:

Serum glucose 600 mg/dL. This is an expected finding for a client who has diabetic ketoacidosis (DKA) DKA results from a deficiency of insulin, which leads to hyperglycemia and ketosis. The normal range for serum glucose is 70 to 110 mg/dL.

Choice B reason:

Serum bicarbonate 28 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences ketosis, which results in ketones in the urine and blood. The nurse should expect a client who has DKA to have an HCO3- less than 15 mEq/L. This decreased value is due to an increased production of ketones, which results in metabolic acidosis. The normal range for serum bicarbonate is 22 to 26 mEq/L.

Choice C reason:

Serum potassium 2.5 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences osmotic diuresis and subsequent dehydration, which can cause electrolyte imbalances. The nurse should expect a client who has DKA to have elevated serum potassium levels due to the movement of potassium from the intracellular to the extracellular space in response to acidosis. The normal range for serum potassium is 3.5 to 5 mEq/L.

Choice D reason:

Serum sodium 150 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences osmotic diuresis and subsequent dehydration, which can cause electrolyte imbalances. The nurse should expect a client who has DKA to have decreased serum sodium levels due to the dilutional effect of excess glucose in the blood. The normal range for serum sodium is 136 to 145 mEq/L.

A. Cheese. B. Broccoli. C. Almonds. D. Bananas. E. Sardines.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason:

Cheese is a good source of calcium, which is essential for bone health and muscle contraction. Calcium also helps regulate the heart rhythm and blood clotting. Cheese can provide about 200 mg of calcium per ounce.

Choice B reason:

Broccoli is a cruciferous vegetable that contains goitrogens, which are substances that can interfere with thyroid hormone synthesis and cause or worsen hypothyroidism. Hypothyroidism can lead to low levels of parathyroid hormone (PTH), which is responsible for maintaining calcium balance in the body. Therefore, broccoli should be avoided or limited by clients who have hypocalcemia due to hypoparathyroidism.

Choice C reason:

Almonds are rich in magnesium, which is a mineral that helps regulate calcium absorption and metabolism. Magnesium also plays a role in nerve and muscle function, blood pressure, and blood sugar control. Almonds can provide about 80 mg of magnesium per ounce.

Choice D reason:

Bananas are high in potassium, which is a mineral that can affect the balance of calcium in the body. High levels of potassium can cause hyperkalemia, which can lower the serum calcium level by increasing the renal excretion of calcium and decreasing the release of PTH. Therefore, bananas should be avoided or limited by clients who have hypocalcemia due to hypoparathyroidism.

Choice E reason:

Sardines are a type of oily fish that contain vitamin D, which is a fat-soluble vitamin that helps increase the intestinal absorption of calcium and phosphorus. Vitamin D also works with PTH to regulate the bone resorption and formation of calcium. Sardines can provide about 250 IU of vitamin D per 3 ounces.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory report of a client who has diabetic ketoacidosis (DKA) Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is providing dietary teaching to a client who has hypocalcemia due to hypoparathyroidism. Which of the following foods should the nurse recommend? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is planning care for a client who has overhydration and hyponatremia. Which of the following actions should the nurse include in the plan? (Select all that apply.)

A nurse is caring for a client who has hypomagnesemia due to chronic alcohol use disorder. Which of the following actions should the nurse take?

A nurse is reviewing the laboratory results of a client who has chronic kidney disease and notes that the serum phosphate level is elevated. The nurse should anticipate that which of the following electrolyte levels will be decreased?

A nurse is reviewing laboratory results for a client who has hypokalemia. Which of the following findings should the nurse expect?

A nurse is providing discharge instructions to a client who has chronic heart failure and is prescribed furosemide, a loop diuretic. Which of the following dietary modifications should the nurse include in the teaching? (Select all that apply.)

A nurse is evaluating the effectiveness of fluid therapy for a client who has hypernatremia. Which of the following findings indicates improvement? (Select all that apply.)

A patient has been admitted with a potassium level of 6.8 mEq/L. The nurse would expect which of the following electrocardiogram (ECG) changes as a result of this laboratory value?