The nurse is caring for a client who reports frequent nausea and vomiting for the past 24 hours. Which assessment finding requires further action by the nurse?

Pale yellow urine

Oral temperature of 99 F (37.2 C)

Moist mucous membranes

Blood pressure 90/49 mmHg

Answer and Explanation

The Correct Answer is D

Choice A reason:
Pale yellow urine is generally within normal limits and indicates adequate hydration. This finding does not suggest a complication requiring immediate action.

Choice B reason:
An oral temperature of 99 F (37.2 C) is considered a low-grade or normal temperature. It does not indicate infection or dehydration that would require urgent intervention.

Choice C reason:
Moist mucous membranes suggest that the client’s hydration status is currently adequate. This assessment does not raise immediate concern despite ongoing nausea and vomiting.

Choice D reason:
A blood pressure of 90/49 mmHg indicates hypotension, which may result from fluid loss due to persistent vomiting. Hypotension is a sign of potential hypovolemic shock or severe dehydration, requiring prompt nursing assessment and intervention to prevent complications such as organ hypoperfusion or syncope.

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Correct Answer is C

Explanation

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.

A. Ensure a chest x-ray is used to verify correct placement of the PICC before use. B. Apply a sterile dressing to the insertion site per facility protocol. C. Schedule daily blood draws from the PICC line to maintain patency. D. Flush the PICC line with 0.9% sodium chloride before and after use. E. Monitor the insertion site for signs of infection, phlebitis, or infiltration.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:
A chest x-ray is required before using a PICC line to ensure proper placement and prevent complications such as pneumothorax or malposition, which could result in ineffective therapy or injury.

Choice B reason:
Applying a sterile dressing per facility protocol prevents infection at the insertion site and maintains catheter integrity. This is critical for preventing bloodstream infections.

Choice C reason:
Scheduling daily blood draws from the PICC is unnecessary and may increase the risk of infection. Blood should only be drawn as clinically indicated.

Choice D reason:
Flushing the PICC line with 0.9% sodium chloride before and after each use maintains patency, prevents clot formation, and ensures the line remains functional for medication administration or fluid therapy.

Choice E reason:
Regular monitoring of the insertion site for redness, swelling, pain, or discharge allows early identification of infection, phlebitis, or infiltration, ensuring timely intervention and client safety.

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The nurse is caring for a client who reports frequent nausea and vomiting for the past 24 hours. Which assessment finding requires further action by the nurse?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is planning care for a client with a newly inserted peripherally inserted central catheter (PICC). Which interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","B","C","E"]

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