A nurse is caring for a client receiving 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?

Discontinue the existing IV infusion.

Insert an IV catheter in the opposite extremity.

Apply warm, moist compresses to the site.

Elevate the extremity.

Answer and Explanation

The Correct Answer is A

A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.

B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.

C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.

D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.

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Correct Answer is ["D","E"]

Explanation

A. Place the child in prone position:

Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.

B. Restrain the child:

Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.

C. Place a tongue depressor in the child's mouth:

It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.

D. Clear the area of hard objects:

Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.

E. Loosen restrictive clothing:

Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.

A. It is not permissible because the provider should disclose laboratory results or findings to a client. B. It is permissible because the client's sibling made the request. C. It is permissible because the sibling has paid for the service. D. It is not permissible because there is no nurse-client relationship between the sibling and nurse.

Correct Answer is D

Explanation

A. It is not permissible because the provider should disclose laboratory results or findings to a client:

While it is true that the provider should disclose laboratory results or findings to the client, the nurse, in this case, should not be accessing the information on behalf of the sibling without proper authorization.

B. It is permissible because the client's sibling made the request:

Even if the sibling made the request, accessing a client's health information without proper authorization is a violation of privacy and confidentiality.

C. It is permissible because the sibling has paid for the service:

Payment for services does not automatically grant access to health information. Protected health information (PHI) is subject to privacy laws, and access should be granted only to those authorized to receive it.

D. It is not permissible because there is no nurse-client relationship between the sibling and nurse:

This is the correct explanation. The nurse should not access a client's health information, even if it is a family member, without proper authorization. The absence of a nurse-client relationship with the sibling does not justify accessing the client's health information.

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A nurse is caring for a client receiving 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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Correct Answer is D

Explanation

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