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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?

A.

Discontinue the existing IV line.

B.

Initiate a new IV line in the other extremity.

C.

Apply a hot pack to the irritated site.

D.

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 {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

The client’s elevated ammonia level (250 mcg/dL, with a normal range of 10 to 80 mcg/dL) is indicative of hepatic encephalopathy, a condition often seen in patients with cirrhosis. Elevated ammonia levels result from liver dysfunction, leading to a decreased ability to detoxify ammonia. This elevated level contributes to the client's decreased level of consciousness, slurred speech, and impaired concentration.

Correct Answer is B

Explanation

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D. A senior nursing student may not have the required certification or experience to safely double-check blood transfusion products.

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