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 A

Explanation

A. The client's desire to go home so soon after a significant medical event like an MI suggests a possible denial of the severity of his condition and an unwillingness to acknowledge the
need for further medical care and recovery time.

B. While decisional conflict due to stress could be a concern, the client's behavior does not directly indicate stress about making decisions, but rather a disregard for the gravity of his recent health event.
C. Deficient knowledge of lifestyle changes is likely an issue for someone who has just experienced an MI, but the immediate behavior of wanting to leave the hospital does not directly relate to a lack of knowledge about necessary lifestyle changes.
D. Anxiety related to the treatment plan could be present, but the client's behavior of wanting to leave the hospital suggests a coping mechanism of denial rather than anxiety about the treatment itself.

A. Instruct client and family to reconsider end of life choices. B. Teach client how to use guided imagery, C. Record the client's desire to live. D. Encourage family to visit frequently. E. Encourage family to bring the client old photographs

Correct Answer is ["B","D","E"]

Explanation

A. Instructing the client and family to reconsider end of life choices may not be appropriate as it could cause additional stress and conflict during a sensitive time.

B. Teaching the client how to use guided imagery can be a helpful tool in managing anxiety and providing a sense of calm.
C. Recording the client's desire to live is important for documentation, but it does not directly assist in coping with feelings related to death and dying.
D. Encouraging family to visit frequently can provide emotional support and comfort to the client during this difficult time.
E. Encouraging family to bring old photographs can help the client reminisce and find joy in memories, which can be therapeutic.

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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 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Correct Answer is A

Explanation

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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