A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?

Initiate a new IV line below the original insertion site.

Discontinue the infusion.

Raise the head of the bed.

Obtain a culture from the area of the insertion site.

Answer and Explanation

The Correct Answer is B

A. Initiate a new IV line below the original insertion site. – If phlebitis or infection is present, a new IV should be placed in another limb or at a site above the previous insertion, not below.

B. Discontinue the infusion. – The first step in treating suspected phlebitis or IV infiltration is stopping the infusion to prevent further tissue damage.

C. Raise the head of the bed. – Elevating the head of the bed is not relevant in managing IV site complications.

D. Obtain a culture from the area of the insertion site. – Cultures are not necessary unless infection is suspected and prescribed by a provider.

Nursing Test Bank

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Correct Answer is B

Explanation

A. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.

B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.

C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.

D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A. Insert the NG tube is the correct choice because the provider's order specifically states to "insert NG tube to low-intermittent suction." This intervention is a key part of managing acute pancreatitis, especially in clients experiencing nausea, vomiting, and abdominal distention.

B. Decompress the stomach and reduce vomiting is the correct reason because an NG tube helps remove gastric contents, reducing the stimulation of pancreatic enzyme secretion, which worsens inflammation. It also alleviates symptoms of nausea and vomiting, helping prevent further fluid loss and electrolyte imbalances.

Incorrect answers:

B. Administer prescribed antibiotics: There is no mention of an order for antibiotics in the provider’s prescriptions.

C. Perform abdominal assessment: While an abdominal assessment is always part of nursing care, it is not the primary action to implement the provider’s prescription. The nurse should still monitor for worsening symptoms, such as peritoneal signs or increasing distention.

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A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the lists of options. To implement the provider's prescriptions the nurse should dropdown because this will dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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