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?

Discontinue the existing IV line.

Initiate a new IV line in the other extremity.

Apply a hot pack to the irritated site.

Determine if the client needs to continue IV therapy.

Answer and Explanation

The Correct Answer is A

A. The first action should be to discontinue the existing IV line to prevent further damage and reduce the risk of complications, such as phlebitis or infiltration.
B. Initiating a new IV line is necessary, but it should be done after addressing the issue with the current IV site.
C. Applying a hot pack might help with comfort, but addressing the cause of the irritation (discontinuing the IV) is more critical first.
D. Determining if the client needs to continue IV therapy is important but should follow the immediate step of addressing the current IV site issue.

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Correct Answer is A

Explanation

A. Bladder distension is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries above T-6. It is crucial to manage bladder function to prevent this potentially life-threatening condition.

B. Elevated blood pressure is a sign of autonomic dysreflexia rather than a predisposing factor. Identifying the trigger, such as bladder distension, is essential before addressing the elevated blood pressure.

C. Nasal congestion is not typically associated with autonomic dysreflexia. While it might be uncomfortable, it is not a common trigger for this condition.

D. A severe headache can be a symptom of autonomic dysreflexia, but identifying the underlying cause or trigger, such as bladder distension, is essential for proper management.

A. Perform neurovascular checks of the extremities. B. Direct the client to perform exercises of the ankle and toes. C. Instruct the client on use of crutches. D. Medicate the client for pain.

Correct Answer is A

Explanation

A. Performing neurovascular checks of the extremities is critical to detect signs of complications such as impaired circulation or nerve damage, which can occur after orthopedic surgery. This assessment is essential for early identification of potential issues.

B. While performing exercises of the ankle and toes is important for preventing complications like deep vein thrombosis, it is secondary to ensuring neurovascular integrity.

C. Instructing the client on the use of crutches is necessary for mobility and safety, but it follows the priority of monitoring for neurovascular complications.

D. Medicating the client for pain is important for comfort, but addressing potential neurovascular issues is a higher priority in the immediate postoperative period to prevent serious complications.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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