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.

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Correct Answer is D

Explanation

A. Calcium Chloride: This is used to treat hypocalcemia, not hypercalcemia.
B. Spironolactone (Aldactone): This is a potassium-sparing diuretic, which does not affect calcium levels.
C. Kayexalate: This is used to treat hyperkalemia, not hypercalcemia.
D. Calcitonin: This is used to lower high serum calcium levels by inhibiting bone resorption and increasing calcium excretion.

A. The 22-year-old client who does not understand English B. The 17-year-old client who has two fractured wrists C. The 65-year-old client who cannot read or write D. The 80-year-old client who is not oriented to the day

Correct Answer is D

Explanation

A. The 22-year-old client who does not understand English: This client can still consent legally if provided with a translator or interpreter to ensure understanding.
B. The 17-year-old client who has two fractured wrists: This client is a minor and would typically need a legal guardian to consent, but their ability to consent is not the primary issue here.
C. The 65-year-old client who cannot read or write: Literacy issues do not necessarily preclude the ability to understand and consent, especially if the consent process is explained to them.
D. The 80-year-old client who is not oriented to the day: This client lacks orientation and thus may not be able to fully understand or make an informed decision about the surgery, affecting their ability to consent legally.

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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

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