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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:
Abdominal bloating can occur in many conditions and is not specific to endometriosis.
Choice B rationale:
An atypical Papanicolaou smear is not related to endometriosis, it’s more associated with cervical abnormalities.
Choice C rationale:
A history of pelvic inflammatory disease (PID) is not a specific indicator of endometriosis.
Choice D rationale:
Dysmenorrhea (painful menstrual periods) that is unresponsive to NSAIDs is a common symptom of endometriosis.

A. Notify the nurse manager. B. Monitor the client for hypoglycemia. C. Complete an incident report. D. Give the client 15 to 20 g of carbohydrate.

Correct Answer is B

Explanation

Choice A rationale:
Notifying the nurse manager is important, but it’s not the priority action.
Choice B rationale:
Monitoring the client for hypoglycemia is the priority because the nurse administered an excessive insulin dose.
Choice C rationale:
Completing an incident report is necessary, but it’s not the priority action.
Choice D rationale:
Giving the client 15 to 20 g of carbohydrate might be necessary if the client shows signs of hypoglycemia.

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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?

Nursing Test Bank

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A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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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?