A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

Flush the IV site with normal saline, then restart the IV potassium therapy

Discontinue the IV and restart in another site

Flush the IV site with heparin

Stop the IV site and check for blood return

Answer and Explanation

The Correct Answer is B

A. Flush the IV site with normal saline, then restart the IV potassium therapy: Flushing and restarting the infusion at the same site is not appropriate if there is redness and swelling, as these are signs of possible phlebitis or infiltration.
B. Discontinue the IV and restart in another site: This is the correct choice. Given the erythema and edema, which indicate possible complications like phlebitis or infiltration, the IV should be discontinued and restarted in a new site to prevent further complications.
C. Flush the IV site with heparin: This is not appropriate for erythema and edema and could exacerbate the problem. Heparin is used to maintain patency of IV lines, not to treat complications.
D. Stop the IV site and check for blood return: While checking for blood return is a good practice to assess for patency, the primary action should be to discontinue the IV and start a new one due to the complications at the site.

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Correct Answer is A

Explanation

A. Pulmonary embolism: Pulmonary embolism presents with sudden onset of chest pain, tachycardia, hypotension, and restlessness, which aligns with the client's symptoms. It is a common postoperative complication due to immobility and potential hypercoagulability.
B. Pneumonia: Pneumonia typically develops more gradually and presents with fever, productive cough, and respiratory distress rather than sudden chest pain and hemodynamic instability. It is less likely in the immediate postoperative period.
C. Hemorrhage: Hemorrhage would also cause tachycardia and hypotension, but it would typically present with symptoms such as excessive bleeding, swelling at the surgical site, and pallor rather than chest pain.
D. Myocardial infarction: While myocardial infarction can cause chest pain, tachycardia, and hypotension, it is less likely in this scenario compared to a pulmonary embolism, given the timing and nature of the symptoms in the immediate postoperative period.

A. Infiltration B. Phlebitis C. Extravasation D. Infection E. - E. Limited ambulation

Correct Answer is B

Explanation

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

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A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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