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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Serum potassium 3.2 mEq/L: A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac arrhythmias and muscle weakness. This condition requires prompt correction and collaboration with the healthcare provider before surgery to avoid intraoperative and postoperative complications.
B. Pulse rate 65 bpm: A pulse rate of 65 bpm is within the normal range (60-100 bpm). While it should be monitored, it does not require immediate intervention or collaboration with the healthcare provider before surgery.
C. Hematocrit 36%: A hematocrit level of 36% is within the lower end of the normal range (35-45% for women). This does not indicate an immediate concern that requires prompt collaboration with the healthcare provider.
D. Blood pressure 144/82 mmHg: Although this blood pressure reading is slightly elevated, it is not uncommon and can be managed perioperatively. It does not require immediate intervention before surgery.

A. Administer 10% sodium chloride via rapid infusion B. Administer intranasal antidiuretic hormone C. Encourage oral fluid intake D. Place the client on seizure precautions

Correct Answer is D

Explanation

A. Administer 10% sodium chloride via rapid infusion: Rapid infusion of high concentrations of sodium chloride can be dangerous and is not the standard treatment for severe hyponatremia.
B. Administer intranasal antidiuretic hormone: This would not be appropriate for correcting severe hyponatremia and could potentially worsen the condition.
C. Encourage oral fluid intake: For severe hyponatremia, oral fluid intake might not be sufficient and could exacerbate the condition if there is fluid overload.
D. Place the client on seizure precautions: This is the correct choice. Severe hyponatremia (sodium < 120 mEq/L) can lead to neurological symptoms and seizures, so implementing seizure precautions is crucial for safety.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who takes furosemide (Lasix) and propranolol (Inderal) is scheduled for breast reconstruction surgery. Which additional client information requires prompt collaboration with the healthcare provider before surgery?

Correct Answer is A

Explanation

The client is admitted with a serum sodium level of 110 mEq/L. What nursing intervention should be implemented?

Correct Answer is D

Explanation

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

A student nurse is working with their preceptor on a medical-surgical unit. While reviewing concepts related to acid-base balance, what should the preceptor state is a compensatory mechanism for metabolic alkalosis?

When planning nutritional interventions for a healthy 83-year-old man, the nurse recognizes what factor is most likely to affect his nutritional status?

A client is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics did this client most likely receive?

A nurse is preparing the skin of a client scheduled for cardiac surgery. What is the purpose of surgical skin cleaning preparation?

A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?