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 C
Explanation
Choice A rationale:
Encouraging brief exercise before meals to promote appetite is not directly related to feeding safety for a client who has dysphagia following a stroke.
Choice B rationale:
Placing the client with the head reclined back to facilitate swallowing is incorrect. It’s safer for the client to sit upright during feeding to prevent aspiration.
Choice C rationale:
Encouraging the client to take small bites can help prevent choking and aspiration, making it a safe feeding practice for clients with dysphagia.
Choice D rationale:
Placing food in the affected side of the mouth is not a safe practice. It’s recommended to place food on the unaffected side of the mouth.
Correct Answer is C
Explanation
Choice A rationale:
Weight reduction programs are generally beneficial for type 2 diabetes, not type 1.
Choice B rationale:
Insulin does not permit unrestricted dietary choices.
Choice C rationale:
Insulin injections are often given in the abdominal area due to its high vascularity, promoting faster absorption.
Choice D rationale:
Blood sugar readings are typically taken before meals to determine insulin dosage.
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