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. Securing the chest tube to the stretcher is important, but not the most critical action as it does not directly affect the function of the chest tube during transport.
B. Administering pain medication is important for comfort but is not the most immediate concern during urgent transport for a CT scan.

C. Marking the amount of chest drainage is a routine monitoring action and can be done before or after transport, thus not the most critical action.
D. Keeping the chest tube container below the site of insertion is crucial to maintain proper
drainage by gravity and prevent complications such as tension pneumothorax, which can be life- threatening.

A. Initiate seizure precautions. B. Monitor serum potassium frequently. C. Assess pupillary response to light hourly. D. Measure urinary output every hour.

Correct Answer is D

Explanation

A. Initiate seizure precautions: Dopamine administration does not typically require seizure
precautions. The focus should be on monitoring for adverse effects related to blood pressure and urinary output.
B. Monitor serum potassium frequently: While electrolyte imbalances can occur with dopamine administration, the priority is to monitor urinary output as dopamine affects renal perfusion and urine output.
C. Assess pupillary response to light hourly: Monitoring pupillary response is important in some situations, but it's not the primary concern with dopamine administration.
D. Measure urinary output every hour: Correct! Dopamine is administered to improve renal perfusion and increase urine output in hypotensive patients. Monitoring urinary output every
hour is essential to assess the effectiveness of dopamine therapy and detect any signs of renal dysfunction or worsening hypotension.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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