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?

Discontinue the existing IV line.

Initiate a new IV line in the other extremity.

Apply a hot pack to the irritated site.

Determine if the client needs to continue IV therapy.

Answer and Explanation

The Correct Answer is A

A. The first action should be to discontinue the existing IV line to prevent further damage and reduce the risk of complications, such as phlebitis or infiltration.
B. Initiating a new IV line is necessary, but it should be done after addressing the issue with the current IV site.
C. Applying a hot pack might help with comfort, but addressing the cause of the irritation (discontinuing the IV) is more critical first.
D. Determining if the client needs to continue IV therapy is important but should follow the immediate step of addressing the current IV site issue.

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Correct Answer is A

Explanation

A. Limiting the number of health care workers entering the room helps reduce the risk of infection for immunosuppressed clients, who have weakened immune systems and are more susceptible to infections.
B. For clients with immunosuppression, monitoring the temperature more frequently (e.g., every 4 hours) is important to promptly identify signs of infection.
C. Providing fresh fruit might introduce potential sources of infection; it is safer to provide well-cooked or processed fruits.
D. Inserting an indwelling catheter may increase the risk of infection, and it is generally better to use less invasive methods unless absolutely necessary.

A. Place the client on his left side in Trendelenburg position. B. Replace the infusion system. C. Remove the catheter. D. Prepare for chest tube insertion. E. Prepare for chest tube insertion.

Correct Answer is A

Explanation

A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.

B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.

C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.

D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.

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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?