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 C

Explanation

A. The presence of clear, pale red liquid drainage from the rectal tube suggests possible bleeding or other issues that need prompt assessment, making this client a priority.

B. Dark red drainage on a postoperative dressing could indicate bleeding, which requires immediate attention to assess the extent of bleeding and intervene accordingly.

C. Clients with compressed Jackson-Pratt drains may not have adequate drainage, potentially leading to complications such as hematoma or infection if the drain becomes obstructed.

However, since the bulb is compressed, indicating no active drainage, this client can be assessed later.

D. A distended abdomen with no drainage from the nasogastric tube could indicate a bowel obstruction or other gastrointestinal issue requiring urgent assessment, making this client a priority for assessment.

A. Determine if the mother has recently experienced a fall. B. Review the client's current food and medication allergies. C. Encourage increased intake of high protein foods. D. Instruct the daughter to check her mother's temperature. E. Ask if the mother is experiencing any pain with

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

Explanation

A. Confusion can be a sign of a concussion or other injury resulting from a fall, which is a common risk for individuals with Parkinson's disease.
B. Reviewing the client's current food and medication allergies is important as allergies can contribute to confusion if the client is exposed to an allergen.
C. Encouraging increased intake of high protein foods is generally recommended for individuals with Parkinson's disease, but it is not directly related to the acute onset of confusion.
D. Checking the mother's temperature is a direct action to assess for infection, which can be a cause of acute confusion, especially in older adults.
E. Pain with urination could indicate a urinary tract infection, which is another common cause of confusion in the elderly. It is important to assess for this possibility.

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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

After receiving report, the nurse can most safely plan to assess which client last?

Correct Answer is C

Explanation

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

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

Explanation

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