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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Determining the need for urinary catheterization is within the scope of a registered nurse (RN), as it involves assessment and clinical judgment. A practical nurse (PN) does not independently determine the need for catheterization.
B. Titrating oxygen within prescribed parameters is an appropriate task for a PN, as it involves following provider orders and monitoring the client's response while working under RN supervision.
C. Receiving a postoperative client and conducting the initial assessment requires comprehensive assessment skills, which fall within the RN's scope of practice rather than the PN's.
D. Evaluating and updating plans of care require critical thinking and clinical decision-making, which are responsibilities of the RN. The PN can contribute to care but does not independently evaluate or modify care plans.

A. Place an indwelling urinary catheter and measure strict intake and output. B. Keep the bed in the lowest position and initiate seizure and fall precautions. C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Maintain elevated positioning of the dependent joints on the affected side.

Correct Answer is C

Explanation

A. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for comprehensive assessment and management but is not the priority action in this situation, which suggests a possible stroke.

B. Keeping the bed in the lowest position and initiating seizure and fall precautions are important for safety, but the client's symptoms are suggestive of a stroke, and immediate evaluation and potential treatment are needed.

C. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the priority action. The client's symptoms, including right-sided weakness and sluggish speech, suggest a potential ischemic stroke. IV fibrinolytic therapy (e.g., tissue plasminogen activator) is time-sensitive and may be indicated for eligible patients with acute ischemic stroke.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority action in this situation. Immediate assessment and potential treatment for a suspected stroke are needed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel Which task should the nurse assign to the PN?

Correct Answer is B

Explanation

The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is C

Explanation

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?