A nurse assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

Stop the infusion of IV fluids

Apply cold compresses to the IV site

Elevate the extremity on a pillow

Flush the catheter with normal saline

Answer and Explanation

The Correct Answer is A

A. Stop the infusion of IV fluids:

This action may be appropriate if there are signs of infiltration or extravasation, where the IV fluid leaks into the surrounding tissue instead of entering the vein. Stopping the infusion can help prevent further tissue damage and assess the extent of the infiltration.

B. Apply cold compresses to the IV site:

Cold compresses can help reduce swelling and discomfort at the IV site. This action may be appropriate if there are signs of local inflammation or mild irritation at the insertion site.

C. Elevate the extremity on a pillow:

Elevating the extremity can help reduce swelling and promote venous return. This action is beneficial if there is edema or localized swelling above the IV site.

D. Flush the catheter with normal saline:

Flushing the catheter with normal saline is not typically the initial action in response to edema and tenderness above the IV site. Flushing is more commonly performed to ensure patency and proper functioning of the IV catheter.

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Correct Answer is C

Explanation

A. Inform the client that the recovery nurse will instruct them how to manage postoperative pain:

This is an important aspect of postoperative care, but it is typically addressed by the post-anesthesia care unit (PACU) or recovery nurse after surgery rather than in the preoperative education phase. While pain management education is crucial, the focus of preoperative education is usually on what to expect before, during, and immediately after surgery.

B. Remind the client they will return to their room after surgery:

This information is part of the preoperative instructions and helps alleviate anxiety by providing clarity about the post-surgical process. However, it may not be the most critical aspect of preoperative education compared to other options.

C. Provide instructions about how to cough and deep breathe effectively:

This is a key nursing intervention to include in preoperative education. Teaching the client how to cough and deep breathe effectively helps prevent postoperative complications such as atelectasis and pneumonia. These breathing techniques are typically taught preoperatively to ensure the client understands and can perform them correctly after surgery.

D. Notify the client that they will receive a food tray in the recovery room:

While it's important for the client to understand the postoperative diet plan, including any dietary restrictions or instructions, this information is usually provided after surgery rather than in the preoperative education phase.

A. High-protein diet with vitamins and mineral supplements B. Low-fat diet with whole grains and cereals and vitamin supplements C. Vegetarian diet with nutritional supplements and fish oil capsules D. low cholesterol, high-fiber, low-carbohydrate diet

Correct Answer is A

Explanation

A. High-protein diet with vitamins and mineral supplements:

This choice indicates a good understanding of preventing pressure ulcers. High-protein diets are beneficial for tissue repair and wound healing. Adequate protein intake supports collagen synthesis, which is essential for maintaining skin integrity and healing wounds. Additionally, vitamins and mineral supplements can contribute to overall nutritional status and support tissue health.

B. Low-fat diet with whole grains and cereals and vitamin supplements:

While a low-fat diet and whole grains are generally healthy choices, they may not specifically address the needs of a patient at risk for pressure ulcers. Fat is important for skin health, and whole grains can contribute to overall nutrition, but protein and specific vitamins and minerals are more directly related to tissue repair and wound healing.

C. Vegetarian diet with nutritional supplements and fish oil capsules:

A vegetarian diet can be healthy, but it requires careful planning to ensure adequate protein intake, especially for tissue repair and wound healing. Nutritional supplements may help fill nutrient gaps, but specific attention to protein sources is crucial for preventing pressure ulcers. Fish oil capsules can provide omega-3 fatty acids, which may have some benefits for skin health.

D. Low cholesterol, high-fiber, low-carbohydrate diet:

This diet choice focuses more on cardiovascular health and weight management rather than addressing the needs of a patient at risk for pressure ulcers. While a balanced diet with adequate fiber can support overall health, protein intake and specific vitamins and minerals are more critical for skin integrity and wound healing.

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A nurse assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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