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 B

Explanation

Choice A rationale:
Placing the client back in bed during a seizure could potentially cause injury. The priority is to protect the client from harm during the seizure.
Choice B rationale:
Placing the client on his side, specifically the recovery position, helps keep the airway clear and prevents aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause injury. It’s important to let the seizure take its course while protecting the client from harm.
Choice D rationale:
Inserting a tongue blade or any other object in the client’s mouth during a seizure is not recommended. It could cause injury to the client or the nurse.

A. Dextrose 10% in water. B. 3% sodium chloride. C. 0.9% sodium chloride. D. Lactated Ringer's. .

Correct Answer is A

Explanation

Choice A rationale:
Dextrose 10% in water can be used as a temporary replacement for TPN to prevent hypoglycemia until the TPN solution is available.
Choice B rationale:
3% sodium chloride is a hypertonic solution and is not typically used as a replacement for TPN.
Choice C rationale:
0.9% sodium chloride, or normal saline, does not provide the necessary nutrients that are included in TPN.
Choice D rationale:
Lactated Ringer’s is used for fluid resuscitation and does not provide the necessary nutrients that are included in TPN.

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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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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?