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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Placing the legs in a dependent position can increase venous pressure and exacerbate venous insufficiency.
Choice B rationale:
Bed rest can lead to venous stasis and worsen venous insufficiency.
Choice C rationale:
Using elastic stockings can help improve venous return and reduce symptoms of venous insufficiency.
Choice D rationale:
Applying ice packs can constrict blood vessels and reduce blood flow, which is not recommended for venous insufficiency.
Correct Answer is B
Explanation
Choice A rationale:
Urinary retention is not typically associated with menopause.
Choice B rationale:
Dryness with intercourse is a common symptom of menopause due to decreased estrogen levels.
Choice C rationale:
An elevation in body temperature above 37.8° C (100° F) is not typically associated with menopause.
Choice D rationale:
Decreased blood pressure is not typically associated with menopause.
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