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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An elevated WBC count with increased immature neutrophils (bands) indicates an acute infectious process. The presence of bands suggests that the body is responding to an infection and producing neutrophils rapidly to fight off the infection.
B. An allergic reaction is more commonly associated with an elevated eosinophil count rather than neutrophils. The laboratory findings described do not support an allergic reaction.
C. Neutropenia is characterized by a low neutrophil count, not an elevated one. The presence of increased immature neutrophils suggests an infection rather than neutropenia.
D. A resolving inflammatory process would typically show a decrease in immature neutrophils (bands) and a normalization of the WBC count, rather than an elevated WBC with increased bands.
Correct Answer is C
Explanation
A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.
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