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 ["A","B","C","E"]

Explanation

A. Placing the bedside table within the client's reach helps to minimize the need for the older adult to reach or stretch, reducing the risk of falls.

B. Keeping the bed at a comfortable working height makes it easier for the older adult to get in and out of bed safely.

C. Keeping a night light on in the client's room and bathroom helps improve visibility during the night, reducing the risk of tripping or falling.

D. Administering a sedative at bedtime is generally not recommended as a preventive measure for falls. Sedatives can increase the risk of drowsiness and impaired balance, contributing to falls.

E. Locking the wheels on beds and wheelchairs during transfers helps ensure stability and prevents the equipment from moving unexpectedly, reducing the risk of falls during transfers.

A. Salmeterol B. Diazepam C. Misoprostol D. Penicillin G

Correct Answer is B

Explanation

A. Salmeterol:

Salmeterol is a long-acting beta-agonist bronchodilator used for respiratory conditions. While it does not directly cause sedation, the individual response may vary, and caution should be taken if the client experiences dizziness or lightheadedness.

B. Diazepam:

Diazepam is a medication that belongs to the benzodiazepine class and can cause sedation, drowsiness, and impaired coordination. These side effects increase the risk of falls, especially in older adults. Fall precautions may include measures such as bed alarms, non-skid socks, and close monitoring when the client is ambulating.

C. Misoprostol:

Misoprostol is a medication used to prevent gastric ulcers, and it does not typically cause sedation or affect coordination.

D. Penicillin G:

Penicillin G is an antibiotic and does not have sedative effects that would necessitate fall precautions.

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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

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