A nurse is monitoring an intravenous infusion for a client who is dehydrated. The nurse should discontinue the IV for which of the following findings?
Serous drainage at the catheter insertion site
Small air bubble noted in the tubing
Blood return noted in the tubing
Blanched skin at the catheter insertion site
The Correct Answer is D
Choice A reason: Serous drainage at the insertion site may indicate mild irritation but does not require discontinuation unless accompanied by signs of infection or infiltration.
Choice B reason: A small air bubble in the tubing is generally harmless and does not require discontinuation. Large air bubbles pose a risk of air embolism, but small ones are typically absorbed without issue.
Choice C reason: Blood return in the tubing indicates that the IV catheter is correctly placed in the vein. This is a normal finding and does not require discontinuation.
Choice D reason: Blanched skin at the insertion site indicates infiltration, meaning IV fluid is leaking into surrounding tissue rather than the vein. This can cause tissue damage and requires immediate discontinuation of the IV to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Avocados contain tyramine, which can interact with monoamine oxidase inhibitors (MAOIs) like phenelzine, leading to hypertensive crisis. This option is unsafe and incorrect.
Choice B reason: Apple slices are safe because they do not contain tyramine. They are appropriate for clients taking MAOIs and provide a healthy, low-risk snack. This makes option B the correct answer.
Choice C reason: Bologna is a processed meat that contains high levels of tyramine. Consuming it while on phenelzine can trigger dangerous hypertensive reactions. This option is incorrect.
Choice D reason: Cheddar cheese is aged and contains tyramine. Aged cheeses are contraindicated for clients taking MAOIs due to the risk of hypertensive crisis. This option is incorrect.
Correct Answer is B
Explanation
Choice A reason: Informing the provider is necessary, but it is not the first action. Before contacting the provider, the nurse must gather immediate data to assess the severity of the client’s condition. Without objective information, communication with the provider may be incomplete or delayed in urgency.
Choice B reason: Obtaining a pulse oximetry reading is the priority because the client is experiencing shortness of breath and chest pain, which may indicate impaired oxygenation. Pulse oximetry provides rapid, non-invasive data about oxygen saturation, guiding immediate interventions. This step ensures that the nurse can quickly determine if supplemental oxygen or emergency measures are required.
Choice C reason: Administering pain medication is important for comfort, but pain management is not the priority when the client shows signs of possible respiratory compromise. Addressing oxygenation and circulation must come before pain relief in acute trauma situations.
Choice D reason: Requesting a chest x-ray is appropriate for diagnostic purposes, but it is not the first action. Imaging takes time and requires physician orders. Immediate assessment of oxygenation is more urgent to stabilize the client before further diagnostics.
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