The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

A sluggish blood return

Cool sensation above the site

Iced streak tracking the vein

Circumferential skin irritation

Answer and Explanation

The Correct Answer is C

A. A sluggish blood return: While a sluggish blood return may indicate potential issues with the IV line, it does not require immediate intervention unless accompanied by other signs of
complications.
B. Cool sensation above the site: Cool sensation above the site may indicate impaired circulation, but it is not as concerning as other findings requiring immediate intervention.
C. Iced streak tracking the vein: Correct! An iced streak tracking the vein suggests infiltration of IV fluids into the surrounding tissue, which can cause tissue damage and compromise the
effectiveness of the IV therapy. Immediate intervention is needed to prevent further complications.
D. Circumferential skin irritation: Circumferential skin irritation may indicate an allergic reaction or contact dermatitis, which requires attention but is not as urgent as an infiltration.

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Correct Answer is ["B","H"]

Explanation

A. Chesty: Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B. Start oxygen 3 L via nasal cannulA Increased oxygen flow is necessary to manage the

client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C. Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.

D. Normal saline 150 ml/hour: Helps maintain hydration but is secondary to respiratory support in this scenario.
E. NPO: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F. Start an IV: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G. Sputum culture: Useful for diagnosing the cause of respiratory symptoms but not a first- line action.
H. Place the client on a cardiorespiratory monitor: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. Notify the healthcare provider. B. Prepare a continuous heparin infusion per protocol. C. Provide supplemental oxygen. D. Bring the emergency crash cart to the bedside.

Correct Answer is C

Explanation

A. While notifying the healthcare provider is important, the priority is to address the client's immediate physiological needs.
B. Starting a continuous heparin infusion is important in the management of a pulmonary embolus, but providing oxygen is the first priority to ensure adequate oxygenation.

C. Providing supplemental oxygen helps alleviate hypoxia, which is critical in the management of a pulmonary embolus.
D. Bringing the emergency crash cart may be necessary if the client's condition deteriorates, but providing oxygen takes precedence in the initial management.

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The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","H"]

Explanation

Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?

Correct Answer is C

Explanation

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