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 ["A","E"]

Explanation

A. Consuming foods high in saturated fats can contribute to the progression of coronary artery

disease by increasing levels of LDL cholesterol, which can lead to plaque buildup in the arteries. Therefore, advising the client to consume foods with saturated fats would be counterproductive to slowing the progression of the disease.
B. Walking for 30 minutes per day is a beneficial lifestyle change that can help improve

cardiovascular health by promoting physical activity and increasing circulation. This statement does not require additional education.
C. Using a salt substitute may be advisable for individuals with coronary artery disease to reduce sodium intake and lower blood pressure. This statement does not require additional education.

D. Keeping a food diary is a helpful strategy for monitoring dietary habits and identifying areas for improvement. This statement does not require additional education.
E. Eating more canned vegetables may not be the healthiest choice as canned vegetables often contain added sodium, which can contribute to hypertension and cardiovascular disease.
Encouraging the consumption of fresh or frozen vegetables would be a better dietary recommendation.
F. Including oatmeal for breakfast is a nutritious choice that can help lower cholesterol levels and improve heart health. This statement does not require additional education.

A. Explain to the client that the dosage has been changed. B. Withhold the medication until the dosage can be confirmed. C. Inform him that he may refuse the medication and document whether or not he takes it. D. Tell him to take the medication then verify the dosage at the next healthcare team meeting.

Correct Answer is B

Explanation

A. Explaining that the dosage has been changed is not appropriate without verifying the correct dosage first.
B. Withholding the medication until the dosage can be confirmed is the safest approach to prevent potential medication errors.
C. Informing the client that he may refuse the medication is an option, but it does not address the potential discrepancy in dosage.
D. Telling him to take the medication and then verifying the dosage at the next healthcare team meeting could result in a medication error and is not a safe practice

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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

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Explanation

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