The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
Discontinue the intravenous line
Complete an incident report
Start a new IV in the right hand
Place a warm compress over the site
The correct answer is A.
The Correct Answer is A
A. Discontinue the intravenous line: The presence of tenderness and a red streak suggests phlebitis or possibly an early sign of infection. The first and most important step is to discontinue the IV line to prevent further irritation or infection.
B. Complete an incident report: While documentation is important, it is not the first action to take. Immediate attention should be given to the client’s physical condition before completing any paperwork.
C. Start a new IV in the right hand: While starting a new IV is necessary for continued therapy, the first action should be to remove the current IV line to prevent further complications. Starting a new IV can be done immediately afterward.
D. Place a warm compress over the site: A warm compress can help alleviate pain and reduce inflammation, but the priority action is to discontinue the IV line to stop further damage or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.
Correct Answer is D
Explanation
A. Continue monitoring the client: The client's vital signs, pale and cool skin, and low urine output suggest potential hypovolemic shock or other serious postoperative complications, requiring more immediate intervention than just continued monitoring.
B. Increase nasal oxygen flow rate to 8 L: While increasing oxygen may be necessary, the primary concern is the underlying cause of the client's symptoms, which may require more immediate intervention.
C. Place the client in high Fowler's position: This position may be beneficial for certain conditions but does not address the underlying issues suggested by the vital signs and physical findings.
D. Notify the surgeon as soon as possible: This is the correct choice. The client's hypotension, tachycardia, pale and cool skin, and low urine output indicate potential complications that need immediate evaluation by the surgeon.
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