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. Increasing oral fluid intake is not a recommended treatment for skin flushing caused by tadalafil. Skin flushing is a common side effect and usually resolves on its own without the need for increased fluid intake.

B. Advising the client to take nitroglycerin is inappropriate and potentially dangerous. Tadalafil and nitroglycerin both lower blood pressure, and their combined use can lead to a significant drop in blood pressure, which can be life-threatening.

C. Telling the client to go to the emergency department is unnecessary in this case. Skin flushing is a known side effect of tadalafil and does not typically require emergency medical attention unless accompanied by other severe symptoms.

D. Reassuring the client that skin flushing is a common side effect of tadalafil is appropriate. This side effect is generally mild and temporary, and the client should be informed that it is not a cause for concern.

A. Replace the IV site with a smaller gauge B. Apply soft bilateral wrist restraints C. Leave the lights on in the room at night D. Redress the abdominal incision

Correct Answer is D

Explanation

A. Replacing the IV site with a smaller gauge does not address the issue of the client picking at the dressing and tape. It is important to address the primary concern, which is the integrity of the abdominal incision dressing.

B. Applying wrist restraints should be avoided unless absolutely necessary due to the risk of physical and psychological harm to the client. It is not the first-line intervention for addressing dressing and tape disruption.

C. Leaving the lights on in the room at night may help reduce confusion in some clients with dementia but does not address the immediate issue of the disrupted abdominal dressing and IV site.

D. Redressing the abdominal incision is the priority intervention to maintain the integrity of the surgical site and prevent infection. It also addresses the issue of the client picking at the dressing and tape, which could lead to further complications.

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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

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?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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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?

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?