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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Free Nursing Study Resources

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.

A. Administer the solution via a central line. B. Monitor serum sodium levels every 4 hours. C. Titrate the infusion rate according to urine output. D. Assess for signs of fluid overload. E. Keep an accurate intake and output record.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason:

Administer the solution via a central line. This is correct because 3% sodium chloride solution is a hypertonic solution that can cause phlebitis and tissue damage if infused peripherally. A central line can deliver the solution more safely and effectively.

Choice B reason:

Monitor serum sodium levels every 4 hours. This is correct because serum sodium levels can indicate the effectiveness of the therapy and the risk of complications such as hypernatremia or cerebral edema. The normal range of serum sodium is 135 to 145 mEq/L.

Choice C reason:

Titrate the infusion rate according to urine output. This is incorrect because the infusion rate of 3% sodium chloride solution should be titrated according to serum sodium levels, not urine output. Urine output can be affected by other factors such as renal function, fluid intake, and diuretics.

Choice D reason:

Assess for signs of fluid overload. This is correct because 3% sodium chloride solution can cause fluid shifts from the intracellular and interstitial spaces to the intravascular space, leading to fluid overload. Signs of fluid overload include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

Choice E reason:

Keep an accurate intake and output record. This is correct because intake and output records can help monitor the fluid balance and identify any excesses or deficits. Intake includes oral fluids, intravenous fluids, tube feedings, and blood products. Output includes urine, stool, vomitus, drainage, and insensible losses.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 hyponatremia and is receiving IV fluid therapy with 3% sodium chloride solution. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is administering dextrose 10% in water (D10W) to a patient who needs some nutrition with glucose. Which of the following assessments should the nurse perform? (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?

A nurse is evaluating the effectiveness of IV fluid therapy for a client who has dehydration. Which of the following findings indicates improvement?

The nurse is preparing to insert a central venous catheter into a patient's right internal jugular vein using ultrasound guidance. What is an important step that the nurse should perform before inserting the catheter?

A nurse is evaluating a client who has fluid volume overload and received furosemide 40 mg IV bolus 1 hr ago. Which of the following findings indicates that the medication was effective?

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse report to the provider? (Select all that apply.)

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

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?