An intravenous (IV) insertion site begins to leak. The tape over the site is wet. What should the nurse do first?

Replace the IV catheter.

Secure the site with additional tape.

Stop the infusion immediately.

Elevate the affected limb.

Answer and Explanation

The Correct Answer is C

Choice A reason: Replacing the IV catheter may be necessary if the site is compromised, but stopping the infusion first prevents further fluid extravasation, which can cause tissue damage or compartment syndrome due to fluid accumulation in the surrounding tissues.
Choice B reason: Adding tape does not address the leakage, which may indicate infiltration or dislodgement. Continuing the infusion risks extravasation, leading to tissue damage or infection. Stopping the infusion is the priority to prevent further complications.
Choice C reason: Stopping the infusion prevents further fluid leakage into tissues, which can cause infiltration, tissue necrosis, or compartment syndrome. This immediate action minimizes harm, allowing the nurse to assess the site and determine if the catheter is dislodged or infiltrated.
Choice D reason: Elevating the limb may reduce swelling in infiltration but does not address active leakage. Stopping the infusion is critical to prevent further fluid extravasation, which could lead to tissue damage or infection if not addressed promptly.

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Correct Answer is C

Explanation

Choice A reason: Scrubbing the spike with alcohol may not fully sterilize it after contact with a non-sterile surface. Contaminated tubing risks introducing bacteria into the bloodstream, leading to catheter-related infections or sepsis.
Choice B reason: Replacing the IV bag is unnecessary, as the bag was not contaminated. The spike, which contacts the bag’s sterile port, is the compromised component, requiring new tubing to ensure sterility.
Choice C reason: New IV tubing ensures sterility after the spike contacts a non-sterile surface. Contaminated tubing could introduce pathogens into the IV system, causing bloodstream infections. Replacing it maintains the sterile field for safe infusion.
Choice D reason: Wiping with Betadine may not adequately sterilize the spike after contamination. Betadine requires contact time and may leave residue. New tubing is the safest option to prevent infection during IV administration.

A. Mark the time strip on the IV bag with a felt-tip pen. B. Ensure the integrity of the bag. C. Select a vented solution administration set. D. Calculate the tonicity of the solution.

Correct Answer is C

Explanation

Choice A reason: Marking the time strip on the IV bag helps track infusion duration but is not the priority before administration. Ensuring bag integrity prevents contamination or leakage, which could introduce pathogens or cause fluid loss, compromising patient safety and treatment efficacy.
Choice B reason: Checking the IV bag’s integrity ensures it is free from leaks, cracks, or contamination. A compromised bag can introduce bacteria or air into the bloodstream, leading to infections or embolisms. This step is critical for patient safety before initiating infusion.
Choice C reason: Selecting a vented administration set depends on the fluid type and container. While important, it is secondary to ensuring the bag’s integrity, as a damaged bag could lead to contamination or improper fluid delivery, posing immediate risks to the patient.
Choice D reason: Calculating tonicity is unnecessary, as IV fluids are pre-formulated with known tonicity (e.g., isotonic, hypotonic). The nurse’s priority is ensuring the bag is intact to prevent contamination or fluid loss, which directly impacts patient safety and treatment effectiveness.

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An intravenous (IV) insertion site begins to leak. The tape over the site is wet. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Correct Answer is C

Explanation

Before administering a bag of intravenous (IV) fluid, a nurse should confirm the type and amount of solution in the medical record and then do which of the following?

Correct Answer is C

Explanation

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