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 D

Explanation

A. Decreased specific gravity is not typical of right-sided heart failure. Increased specific gravity is often associated with fluid retention.
B. PAWP is more relevant for left-sided heart failure; right-sided heart failure would typically not show an increase in PAWP.
C. BNP levels usually increase in heart failure, including right-sided heart failure, not decrease.
D. Elevated CVP and jugular vein distention are classic signs of right-sided heart failure due to increased venous pressure and fluid overload.

A. Physical therapy B. Low-sodium diet C. MRI of the chest D. Serum cardiac enzyme levels

Correct Answer is C

Explanation

A. Physical therapy is generally appropriate and beneficial post-surgery for mobility and rehabilitation.
B. A low-sodium diet is often recommended for heart health but is not specific to pacemaker insertion.
C. MRI of the chest should be clarified because the magnetic fields from MRI machines can interfere with the pacemaker’s function.
D. Serum cardiac enzyme levels are relevant for monitoring heart function and are appropriate.

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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

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

Correct Answer is C

Explanation

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