The nurse assesses the client’s peripheral intravenous (IV) site and observes a red streak on the forearm that is warm to the touch. Which action should the nurse perform first?

Assess the client’s vital signs.

Apply a cool compress to the IV site.

Remove the IV catheter.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Assessing vital signs is important when infection or systemic involvement is suspected; however, the priority is to stop the source of injury. A red streak and warmth along the vein indicate phlebitis, which requires immediate intervention to prevent progression. Vital signs can be assessed after the offending catheter is removed.

Choice B reason:
Applying a cool compress may help relieve inflammation and discomfort associated with phlebitis, but it does not address the underlying cause. Supportive measures should only be implemented after the IV catheter has been discontinued to prevent further vascular irritation.

Choice C reason:
A red streak and warmth along the vein are classic signs of phlebitis. The first and most important action is to remove the IV catheter to prevent further inflammation, tissue damage, or infection. Removing the source of irritation is the priority intervention according to safety and nursing standards.

Choice D reason:
Notifying the healthcare provider may be necessary if complications develop or further treatment is required. However, this is not the first action. Immediate nursing intervention is required to stop the progression of phlebitis before escalation of care.

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Correct Answer is C

Explanation

Choice A reason:
Caregivers should never attempt to reinsert a PICC line if it becomes dislodged. Reinsertion requires sterile technique and trained personnel due to the risk of infection, air embolism, and vessel injury. This statement indicates incorrect and unsafe understanding of PICC care.

Choice B reason:
While flushing with normal saline is correct, the volume and frequency depend on institutional policy and the type of catheter. Additionally, this statement addresses only one lumen and does not demonstrate full understanding of double-lumen PICC maintenance.

Choice C reason:
Both lumens of a double-lumen PICC must be flushed routinely, even if only one lumen is used. This prevents clot formation, catheter occlusion, and infection. This statement reflects accurate understanding of PICC maintenance and indicates effective learning.

Choice D reason:
PICC dressings are typically changed every 7 days or sooner if they become loose, damp, or soiled. Waiting 8–10 days increases the risk of infection. This statement demonstrates incorrect knowledge regarding dressing change frequency.

A. Ask the healthcare provider to speak with the client. B. Collaborate with the team to convince the client to stay. C. Examine one’s values and beliefs on death and dying. D. Consult the ethics committee to review the client’s case.

Correct Answer is C

Explanation

Choice A reason:
Asking the healthcare provider to speak with the client implies an attempt to change or challenge the client’s decision. The client has expressed acceptance of their prognosis and a clear preference for hospice care. In this situation, the issue is not lack of understanding or need for further medical clarification, but rather the nurse’s internal disagreement. Therefore, involving the provider is not the most appropriate initial action.

Choice B reason:
Collaborating with the team to convince the client to stay violates the ethical principle of autonomy. Clients with decision-making capacity have the right to refuse further treatment and choose hospice care. Attempting to persuade or pressure the client to continue treatment disregards their expressed wishes and may cause emotional distress.

Choice C reason:
When a nurse disagrees with a client’s end-of-life decision, the appropriate action is self-reflection. Examining one’s own values and beliefs about death and dying allows the nurse to provide nonjudgmental, client-centered care. This promotes professional boundaries, respects client autonomy, and ensures that personal beliefs do not interfere with ethical nursing practice.

Choice D reason:
Consulting the ethics committee is appropriate when there is an ethical conflict, uncertainty about decision-making capacity, or disagreement among parties regarding care. In this case, the client’s wishes are clear and ethically sound. The conflict exists within the nurse, not the care plan, making an ethics consultation unnecessary.

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The nurse assesses the client’s peripheral intravenous (IV) site and observes a red streak on the forearm that is warm to the touch. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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