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 D

Explanation

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

A. Increased heart rate. B. Increased respiratory rate. C. Increased temperature. D. Increased hematocrit. E. Increased blood pressure.

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

Explanation

Choice A rationale:
Increased heart rate is a compensatory mechanism to maintain cardiac output in the presence of fluid overload.
Choice B rationale:
Increased respiratory rate may occur due to pulmonary congestion caused by fluid overload.
Choice C rationale:
Increased temperature is not typically associated with fluid overload.
Choice D rationale:
Increased hematocrit would indicate dehydration, not fluid overload.
Choice E rationale:
Increased blood pressure can occur due to increased blood volume in fluid overload.

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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 in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Correct Answer is D

Explanation

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

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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?