Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Apply heat to the infiltrated site.

Document a delay in the administration of the antibiotic.

Start a new IV at a different site to administer the antibiotic.

Remove the infiltrated IV catheter.

Answer and Explanation

The Correct Answer is D

A. Applying heat may be indicated later, but the first action should be to address the infiltration.

B. Documenting the delay is important but not the immediate priority.

C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.

D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.

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Correct Answer is A

Explanation

A. Checking the femoral site for hematoma formation is crucial because pain at the groin insertion site could indicate bleeding or hematoma formation, which is a potential complication of cardiac catheterization.

B. Evaluating the IV insertion site is important but not as directly related to the groin pain as checking the femoral site.

C. Stimulating the client to take deep breaths is helpful for respiratory function but does not address the groin pain issue.

D. Assessing distal lower extremity capillary refill is important for overall circulation but is not the immediate priority in this scenario.

A. Family history of schizophrenia. B. History of suicide attempts. C. Undiagnosed social anxiety symptoms (SAD). D. Feelings of disorientation.

Correct Answer is B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

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Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is B

Explanation

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