A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

Elevate the client's arm to reduce swelling.

Apply a warm compress to the insertion site.

Discontinue the IV infusion immediately.

Administer an analgesic for pain relief.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because elevating the client's arm may not address the underlying complication of infiltration. The nurse's priority is to discontinue the IV infusion to prevent further complications.

B) This choice is incorrect because applying a warm compress is not the priority action. The nurse should first discontinue the IV infusion to assess the site and determine appropriate interventions.

C) This choice is correct. The client's symptoms of pain, burning, redness, swelling, and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues. The nurse's priority is to discontinue the IV infusion to prevent further complications and assess the site for potential tissue damage.

D) This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

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Correct Answer is C

Explanation

A) This choice is incorrect because applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.

B) This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.

C) This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.

D) This choice is incorrect because selecting a small-gauge catheter is not the primary intervention to prevent thrombophlebitis in a client with a history of DVT. The choice of catheter size should be based on the client's clinical needs and vein condition.

A. Administering the medication rapidly to ensure a quick effect. B. Diluting the medication with a large volume of IV fluid. C. Checking the client's allergies and medication compatibility. D. Using a smaller gauge IV catheter for the medication infusion.

Correct Answer is C

Explanation

A) This choice is incorrect because administering the medication rapidly is not necessarily essential and can increase the risk of complications. Medications should be administered at the appropriate rate to prevent adverse effects.

B) This choice is incorrect because diluting the medication with a large volume of IV fluid may be unnecessary and may slow down the administration without specific indications.

C) This choice is correct. Checking the client's allergies and medication compatibility is essential to prevent adverse reactions and complications. Ensuring that the prescribed medication is appropriate for the client and does not interact negatively with other medications or allergies is crucial.

D) This choice is incorrect because the choice of IV catheter size depends on the medication's compatibility and viscosity, not just using a smaller gauge catheter for all medication infusions.

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A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

Correct Answer is C

Explanation

A nurse is preparing to administer an IV medication to a client. Which action is essential to prevent complications during the medication administration?

Correct Answer is C

Explanation

A nurse is caring for a client with a peripheral IV catheter in place. The client complains of tenderness and a palpable, cord-like structure along the vein. The nurse should suspect which complication of IV therapy?

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

A client receiving chemotherapy through an IV complains of pain, burning, and swelling around the IV site. The nurse notices the skin turning red and blistering. Which complication of IV therapy should the nurse suspect?

A nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

A client receiving IV medications develops a painful, warm, and red streak along the arm near the IV site. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A client receiving IV medication complains of sudden chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?