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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "The doctor can best help you with that after your physical examination."
This response implies that a physical examination is necessary before discussing contraception, which may not be accurate. Contraceptive counseling can often occur without a physical examination, and the nurse can provide initial guidance based on the information available.
B. "Before I can help you with that question, I need to know more about your sexual activity."
This response is appropriate because it acknowledges the need for more information to provide personalized advice. It respects the individual's privacy while recognizing that different contraceptive methods may be suitable based on factors like sexual activity, health history, and personal preferences.
C. "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?"
This response may come across as judgmental and could potentially discourage open communication. It's essential to maintain a non-judgmental and supportive attitude when discussing sexual health with adolescents. Instead of questioning their readiness, the focus should be on providing accurate information and support.
D. "Because of your age, we need your parents' consent for an examination, and then we'll talk."
This response may not be appropriate as it suggests a potential barrier to seeking advice about contraception. Many jurisdictions allow adolescents to receive confidential reproductive health services, including contraception, without parental consent. Encouraging open communication and respecting confidentiality is crucial in supporting adolescents' access to reproductive healthcare.
Correct Answer is ["C","D","E"]
Explanation
A. A client who has had prolonged diarrhea:
Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.
B. A client who has lactose intolerance:
Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.
C. A client who has had radiation therapy for head and neck cancer:
Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.
D. A client who has had a stroke:
Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.
E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:
Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.
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