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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Varicose veins with ulcerations and lower extremity edema indicate poor blood flow, hence impaired tissue perfusion is the priority.
Choice B rationale:
While activity tolerance might be affected, it’s not the immediate concern.
Choice C rationale:
Impaired skin integrity is a concern due to ulcerations, but it’s secondary to impaired perfusion.
Choice D rationale:
Body image might be affected, but it’s not a physiological priority.
Correct Answer is A
Explanation
Choice A rationale:
Pulling the curtains around the client’s bed ensures privacy during the procedure.
Choice B rationale:
Asking family members to leave the room might be necessary, but it’s not the priority action.
Choice C rationale:
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
Choice D rationale:
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.
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