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 D
Explanation
A. Coolness at the IV insertion site is not a typical sign of phlebitis. Phlebitis often presents with warmth or increased heat around the vein due to inflammation.
B. Drainage at the IV site might indicate infection or other complications but is not a specific sign of phlebitis. Phlebitis primarily manifests as redness, tenderness, and swelling along the vein.
C. Pallor (pale coloration) at the IV site is not a typical sign of phlebitis. Phlebitis usually presents with redness or erythema due to inflammation.
D. Erythema (redness) at the IV catheter insertion site is a hallmark sign of phlebitis. It indicates inflammation of the vein where the catheter is placed and is a common early sign of phlebitis. Other signs include warmth, tenderness, and swelling along the vein.
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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