While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard.

Which of the following actions should the nurse take first?

Determine if the client needs to continue IV therapy.

Initiate a new IV line in the other extremity.

Discontinue the existing IV line.

Apply a hot pack to the irritated site.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.

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Correct Answer is C

Explanation

Choice A rationale:
Sensitivity to light is a common postoperative symptom after cataract surgery.
Choice B rationale:
Difficulty with depth perception is expected when one eye is patched.
Choice C rationale:
Severe pain is not a normal postoperative symptom and should be reported to the provider.
Choice D rationale:
Itching is a common postoperative symptom after cataract surgery.

A. Localized edema. B. An increase in neutrophils. C. An increase in platelets. D. Bradycardia. E. An increase in RBCS.

Correct Answer is ["A","B"]

Explanation

Choice A rationale:
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
Choice B rationale:
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
Choice C rationale:
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
Choice D rationale:
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
Choice E rationale:
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.

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While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

Correct Answer is C

Explanation

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

Correct Answer is ["A","B"]

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A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard.

Which of the following actions should the nurse take first?