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 C

Explanation

A. Remind the UAP to apply a fitted respirator mask before entering the client's room: While respiratory protection is important when caring for a client with influenza, the situation described does not warrant the use of a fitted respirator mask for the UAP. Standard precautions, including wearing a face mask, gloves, and gown, are typically sufficient for influenza.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: This instruction is important for overall client monitoring but does not directly address the issue of appropriate personal protective equipment (PPE for the UAP.

C. Review the need for the UAP to wear a face mask while in close contact with the client: Correct! The nurse should remind the UAP of the importance of wearing a face mask when providing care to a client with influenza. Face masks help prevent the spread of respiratory droplets and protect both the client and healthcare workers from infection.
D. Assign the UAP to provide care for another client and assume full care of the client: While reassigning the UAP is an option if they are not following proper infection control procedures, it's important to address the issue directly by reminding them of the need for appropriate PPE.

Correct Answer is ["8"]

Explanation

To calculate the dose;

Weight= 20kg

Dose = 30mg/kg/day 8 hourly

Dose per day = 2030= 600mg

8hourly dose= 600/3= 200mg

Volume to give

125mg= 5ml

200mg = 2005/125

= 8ml

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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

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive person (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

Correct Answer is C

Explanation

Correct Answer is ["8"]

Explanation

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