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:
A thrombotic stroke occurs when a blood clot forms in one of the arteries that supply blood to the brain. It does not typically cause a sudden, severe headache and vomiting.
Choice B rationale:
A transient ischemic attack (TIA), or “mini-stroke,” is a temporary blockage of blood flow to the brain. It does not cause a sudden, severe headache and vomiting.
Choice C rationale:
A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the brain. This can cause a sudden, severe headache and vomiting.
Choice D rationale:
An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of stroke does not typically cause a sudden, severe headache and vomiting.

A. Ambulating soon after surgery. B. Massaging her legs. C. Flexing her ankles. D. Elevating her feet.

Correct Answer is B

Explanation

Choice A rationale:
Ambulating soon after surgery is actually encouraged as it promotes blood flow and reduces the risk of VTE.
Choice B rationale:
Massaging the legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Flexing the ankles promotes blood flow and reduces the risk of VTE.
Choice D rationale:
Elevating the feet can reduce swelling and promote venous return, reducing the risk of VTE.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Correct Answer is B

Explanation

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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?