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. Advise the client to place one nitroglycerin tablet under his tongue as a precaution. B. Tell the client to have someone bring him to an emergency department immediately. C. Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. D. Reassure the client that skin flushing is a common side effect of the medication.

Correct Answer is D

Explanation

- A: Nitroglycerin is contraindicated with tadalafil due to the risk of severe hypotension. Advising the client to take nitroglycerin could lead to a dangerous drop in blood pressure.
- B: While it is important to monitor for serious side effects, immediate emergency department care may not be necessary if the client is not experiencing chest pain or other severe symptoms.
- C: Increasing oral fluids does not address the underlying cause of the skin flushing and is not a recommended action for this symptom in relation to tadalafil use.
- D: Skin flushing is a common side effect of tadalafil and is usually self-limiting. Reassuring the client about the nature of this side effect is appropriate, as long as the client is not experiencing chest pain or other severe symptoms related to his history of stable angina.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

Correct Answer is D

Explanation

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A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?