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. While notifying the healthcare provider is important, the priority is to address the client's immediate physiological needs.
B. Starting a continuous heparin infusion is important in the management of a pulmonary embolus, but providing oxygen is the first priority to ensure adequate oxygenation.

C. Providing supplemental oxygen helps alleviate hypoxia, which is critical in the management of a pulmonary embolus.
D. Bringing the emergency crash cart may be necessary if the client's condition deteriorates, but providing oxygen takes precedence in the initial management.

A. Center attention on positive upbeat music. B. Find outlets for more social interaction. C. Practice using muscle relaxation techniques. D. Think about reasons the episodes occur.

Correct Answer is C

Explanation

A. Center attention on positive upbeat music . While positive music can be helpful for some individuals in managing anxiety, it may not be effective for everyone, especially those experiencing moderate anxiety.

B. Find outlets for more social interaction: Increasing social interaction may be beneficial for managing anxiety for some individuals, but it may not address the underlying issues contributing to recurrent moderate anxiety.

C. Practice using muscle relaxation techniques: Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help reduce physical tension and promote relaxation, which can be effective in managing anxiety symptoms.

D. Think about reasons the episodes occur: While understanding triggers for anxiety episodes is important, simply thinking about the reasons may not provide immediate relief or effective coping strategies for managing anxiety symptoms.

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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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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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