Nokea
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. Stop the infusion of intravenous fluids.
Correct Answer: D
Rationale: Edema and tenderness suggest infiltration or phlebitis, requiring immediate cessation of the infusion to prevent further tissue damage. Flushing could worsen the issue, and cold compresses or elevation are secondary actions.
You may also like to solve these questions
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The client's left lower extremity is cool to the touch.
Correct Answer: D
Rationale: A cool extremity suggests decreased blood flow, potentially indicating compartment syndrome, a critical condition that could lead to limb loss if not addressed immediately. The other findings are less urgent.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 101.1°F (37.8°C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct Answer: B
Rationale: Headache and stiff neck, especially with a fever, may indicate meningitis, a life-threatening complication of epidural therapy requiring immediate intervention. Redness, fever, and high pain levels are concerning but less urgent.
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
- A. Begin the prescribed infusion via the new access.
- B. Ensure an x-ray is completed to confirm placement.
- C. Check medication calculations with a second RN.
- D. Make sure the solution is appropriate for a central line.
Correct Answer: B
Rationale: A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
- A. The initial site dressing is 4 days old.
- B. The PICC was inserted 4 weeks ago.
- C. A securement device is absent.
- D. Upper extremity swelling is noted.
Correct Answer: D
Rationale: Upper extremity swelling could indicate infiltration or thrombosis, requiring immediate removal of the PICC to prevent further complications. The other findings are concerning but not as urgent.
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet.
Correct Answer: D
Rationale: Placing a washcloth between the skin and tourniquet protects fragile skin in older adults. The other actions are related to vein distension but do not specifically protect the skin.