The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

A sluggish blood return

Cool sensation above the site

Iced streak tracking the vein

Circumferential skin irritation

Answer and Explanation

The Correct Answer is C

A. A sluggish blood return: While a sluggish blood return may indicate potential issues with the IV line, it does not require immediate intervention unless accompanied by other signs of
complications.
B. Cool sensation above the site: Cool sensation above the site may indicate impaired circulation, but it is not as concerning as other findings requiring immediate intervention.
C. Iced streak tracking the vein: Correct! An iced streak tracking the vein suggests infiltration of IV fluids into the surrounding tissue, which can cause tissue damage and compromise the
effectiveness of the IV therapy. Immediate intervention is needed to prevent further complications.
D. Circumferential skin irritation: Circumferential skin irritation may indicate an allergic reaction or contact dermatitis, which requires attention but is not as urgent as an infiltration.

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Correct Answer is D

Explanation

A. Simply encouraging the client to be calm and relax may not be effective for someone with obsessive-compulsive disorder.

Teaching techniques is more appropriate for structured therapy sessions rather than addressing compulsive behavior in the moment.

C. While identifying stimuli can be useful, it is not an immediate intervention.

This approach respects the client’s need to complete the compulsion to reduce anxiety while gradually redirecting attention, minimizing distress.

A. Mark an outline of the "olive-shaped" mass in the right epigastric area. B. Instruct parents regarding care of the incisional area. C. Monitor the amount of intake and the infant's response to feedings. D. Initiate a continuous infusion of IV fluids per prescription.

Correct Answer is D

Explanation

A. Marking the outline of the "olive-shaped" mass is important for diagnosis but is not the highest priority in pre-operative care.
B. Instructing parents regarding care of the incisional area is important but not the highest priority before surgery.
C.Monitoring feedings is important, but the primary concern is ensuring hydration and electrolyte balance, which may be compromised due to vomiting in pyloric stenosis.

D. IV fluids are essential to correct dehydration and electrolyte imbalances caused by vomiting in pyloric stenosis. This is the highest priority to stabilize the infant before surgery.

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The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?

Correct Answer is D

Explanation

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre- operative nursing action has the highest priority?

Correct Answer is D

Explanation

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