While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard.
Which of the following actions should the nurse take first?
Determine if the client needs to continue IV therapy.
Initiate a new IV line in the other extremity.
Discontinue the existing IV line.
Apply a hot pack to the irritated site.
The Correct Answer is C
Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
Choice B rationale:
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Choice C rationale:
Infection is a risk with burns but it’s not the immediate concern.
Choice D rationale:
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.
Correct Answer is B
Explanation
Choice A rationale:
A pink color with blisters present is indicative of a superficial partial-thickness burn, not a deep partial-thickness burn.
Choice B rationale:
A yellow color with severe edema is indicative of a deep partial-thickness burn. This type of burn involves the entire dermis and damage to nerve endings, blood vessels, and sweat glands.
Choice C rationale:
A black color and absence of pain is indicative of a full-thickness burn, not a deep partial-thickness burn.
Choice D rationale:
A red color with eschar present is indicative of a full-thickness burn, not a deep partial-thickness burn.
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