A nurse is caring for a client receiving intravenous (IV) therapy in the left forearm and notices that the site is red, swollen, and warm.
Which of the following actions should the nurse perform first?

Elevate the extremity.

Insert an IV catheter in the opposite extremity.

Apply warm, moist compresses to the site.

Discontinue the existing IV infusion.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Elevating the extremity may aid in reducing edema by promoting venous and lymphatic return through gravity. However, this is a secondary intervention. The primary concern is stopping the inflammatory insult caused by the IV fluid or catheter, which is achieved by discontinuing the infusion immediately before any other action to prevent further tissue damage.

Choice B rationale

Inserting a new IV catheter is necessary after the affected one is removed, but it's not the first step. The priority is to stop the immediate insult and prevent further complications like cellulitis or abscess formation from the current, inflamed site. The opposite extremity is often chosen for the new site to avoid bilateral issues.

Choice C rationale

Applying warm, moist compresses is a correct subsequent intervention after discontinuing the IV. The heat promotes vasodilation, increasing circulation to the inflamed area, which aids in the absorption of fluids and reduces discomfort, a process known as phlebitis management. This is a treatment, not the initial safety action.

Choice D rationale

Discontinuing the existing IV infusion is the priority action. The signs (redness, warmth, swelling) strongly suggest phlebitis (inflammation of the vein) or infiltration (non-vesicant fluid leakage into surrounding tissue). Immediate removal prevents further chemical or mechanical irritation and potential progression of the inflammatory response or tissue damage.

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Correct Answer is B

Explanation

Choice A rationale

Metabolic alkalosis is characterized by a high pH (normal range 7.35-7.45), indicating alkalinity, and a high HCO_3- (normal range 22-26 mEq/L), indicating a primary metabolic disturbance. The client's pH of 7.26 is acidic, and the HCO_3- of 14 mEq/L is low, which contradicts the parameters for metabolic alkalosis.

Choice B rationale

Metabolic acidosis is defined by a low pH (7.26, acidic) and a low HCO_3- (14 mEq/L). Acute kidney injury often leads to this imbalance because the kidneys are unable to excrete hydrogen ions (H+) and reabsorb or generate bicarbonate (HCO_3-), resulting in a net accumulation of acid in the body. The low PaCO_2 (30 mm Hg, normal range 35-45 mm Hg) indicates a compensatory hyperventilation.

Choice C rationale

Respiratory acidosis is marked by a low pH and a high PaCO_2 (partial pressure of carbon dioxide), reflecting impaired CO_2 excretion by the lungs. The client's PaCO_2 (30 mm Hg) is low, not high, ruling out a primary respiratory acidosis. HCO_3- levels are not the primary disturbance in this case.

Choice D rationale

Respiratory alkalosis is characterized by a high pH and a low PaCO_2. The client's pH (7.26) is low (acidic), not high, which immediately rules out respiratory alkalosis as the primary imbalance. The low PaCO_2 in this scenario is a compensatory mechanism for the metabolic problem.

A. Fully re-collapse the reservoir after emptying it. B. Empty the reservoir once per day. C. Irrigate the tubing with sterile normal saline solution at least once every 8 hr. D. Replace the drainage plug after releasing hand pressure on the device.

Correct Answer is A

Explanation

Choice A rationale

A closed-wound drainage system operates via negative pressure (suction) to facilitate fluid removal and prevent stasis, which could impede healing or promote infection. After emptying the reservoir, it must be fully compressed or "re-collapsed" before sealing the drainage port to re-establish the suction, ensuring continuous, effective wound drainage.

Choice B rationale

The reservoir should be emptied more frequently than once per day, specifically when it is one-half to two-thirds full, or according to facility policy. This action maintains the negative pressure (suction) and prevents the drainage tube from being occluded, promoting optimal wound drainage and decreasing the risk of skin excoriation.

Choice C rationale

Irrigating a closed-wound drainage system is not standard procedure and is generally contraindicated, as it can potentially introduce pathogens into the sterile wound bed, significantly increasing the risk of a wound infection. The system is designed to drain passively under negative pressure.

Choice D rationale

The drainage plug is replaced while maintaining the compression (negative pressure) on the reservoir. Releasing hand pressure before sealing the plug would cause the reservoir to re-expand and lose the vacuum, thereby rendering the suction ineffective for continued wound drainage.

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A nurse is caring for a client receiving intravenous (IV) therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?

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A nurse is caring for a client receiving intravenous (IV) therapy in the left forearm and notices that the site is red, swollen, and warm.
Which of the following actions should the nurse perform first?