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 B

Explanation

A. Support stockings may help with peripheral edema, but they do not address the underlying issue of hypoalbuminemia and its consequences.
B. Adequate protein intake is crucial for increasing serum albumin levels, which can help reduce edema and improve the client's nutritional status. This intervention addresses the root cause of
the client's symptoms.

C. Evaluating the patency of the AV graft is important for long-term planning of hemodialysis access, but it is not the immediate priority given the client's current nutritional status and symptoms.
D. Fluid restriction is important in managing peritoneal dialysis patients, but it does not address the immediate concern of hypoalbuminemia and its effects on the client's health.

A. Secure chest tube to the stretcher for transport. B. Administer PRN pain medication prior to transport. C. Mark the amount of chest drainage on the container. D. Keep chest tube container below the site of Insertion.

Correct Answer is D

Explanation

A. Securing the chest tube to the stretcher is important, but not as critical as keeping the chest tube container below the site of insertion to prevent backflow of fluids.

B. Administering PRN pain medication is important for comfort but is not the priority during urgent transport.

C. Marking the amount of chest drainage is part of ongoing monitoring and does not take precedence over the correct positioning of the chest tube container.

D. Keeping the chest tube container below the site of insertion ensures proper drainage by gravity and prevents complications such as tension pneumothorax.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the take?

Correct Answer is D

Explanation

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