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,A,D,E,B

Explanation

The correct answer is choice C, A, D, E, B. Here are the rationales for each choice: Choice C rationale: Stop the infusion. The first step when an infiltration is identified is to stop the infusion. This is to prevent further infiltration of the IV fluid into the surrounding tissue. Choice A rationale: Remove the IV catheter. After stopping the infusion, the next step is to remove the IV catheter. This is to prevent any more fluid from being infused into the infiltrated area. Choice D rationale: Apply a sterile dressing. Once the IV catheter is removed, a sterile dressing should be applied to the site. This helps to prevent infection. Choice E rationale: Elevate the extremity. The affected extremity should be elevated. This helps to reduce swelling and discomfort. Choice B rationale: Apply warm or cold compresses. Finally, warm or cold compresses should be applied as per the facility’s policy. This can help to alleviate pain and reduce swelling.

A. Obtain a pair of slipper-socks for the client. B. Increase the client's oral fluid intake. C. Rub the client's feet briskly for several minutes. D. Place a moist heating pad under the client's feet.

Correct Answer is A

Explanation

Choice A rationale:
Providing warm slipper-socks can help increase the client’s comfort by keeping their feet warm.
Choice B rationale:
Increasing the client’s oral fluid intake would not directly affect the temperature of their feet.
Choice C rationale:
Rubbing the client’s feet briskly for several minutes could potentially harm the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Choice D rationale:
Placing a moist heating pad under the client’s feet could potentially burn the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.

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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 and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Correct Answer is C,A,D,E,B

Explanation

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is A

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?