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. Document the time the seizure began. B. Turn the client's head to the side. C. Loosen the clothing around the client's waist. D. Check the client's motor strength.

Correct Answer is B

Explanation

A. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.

B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.

C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.

D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.

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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 is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is A

Explanation

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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