A nurse is caring for a patient receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm.
What action should the nurse take first?

Elevate the extremity.

Discontinue the existing IV infusion.

Apply warm, moist compresses to the site.

Insert an IV catheter in the opposite extremity.

Answer and Explanation

The Correct Answer is B

Choice B rationale:

Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.

Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)

Infection

Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)

Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.

Choice A rationale:

Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.

Choice C rationale:

Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.

Choice D rationale:

Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.

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Correct Answer is ["50"]

Explanation

Here are the steps to calculate the gtt/min for the manual IV infusion:

Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes

Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min

Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.

A. A patient who has heart failure and is receiving diuretic therapy. B. A patient who has gastroenteritis and is receiving oral fluids. C. A patient who has end-stage kidney disease who will undergo dialysis. D. A patient who has NPO status since midnight for an endoscopy.

Correct Answer is D

Explanation

Rationale for Choice A:

Diuretics promote fluid loss, increasing the risk of fluid volume deficit.

Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.

However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.

Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.

Rationale for Choice B:

Gastroenteritis can lead to fluid loss through vomiting and diarrhea.

However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.

As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.

Rationale for Choice C:

End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.

However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.

Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.

Rationale for Choice D:

NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.

Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.

Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.

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A nurse is caring for a patient receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm.What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hours. The drop factor of the manual IV tubing is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? (Input your answer into the blank space, without any units. Numerical value only.)

Correct Answer is ["50"]

Explanation

A nurse is collecting data about the fluid status of four patients.Which patient should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

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A nurse is caring for a patient receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm.
What action should the nurse take first?