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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Fluoxymesterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice B rationale:
Danazol is a synthetic steroid that is used to treat endometriosis, but it’s not used for BPH.
Choice C rationale:
Methyltestosterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice D rationale:
Finasteride is a medication that is used to treat BPH. It works by decreasing the size of the prostate gland.
Correct Answer is D
Explanation
Choice A rationale:
While hypertension is a risk factor for stroke, it is modifiable through lifestyle changes and medication.
Choice B rationale:
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice C rationale:
Obesity is a modifiable risk factor for stroke. Weight loss and maintaining a healthy weight can reduce the risk of stroke.
Choice D rationale:
Genetics is a nonmodifiable risk factor for stroke. Individuals with a family history of stroke are at a higher risk, and this cannot be changed.
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