1.A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm,
painful, and slightly edematous near the insertion point of the catheter. On the basis of this
assessment, the nurse s
...
1.A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm,
painful, and slightly edematous near the insertion point of the catheter. On the basis of this
assessment, the nurse should take which action first?
• Remove the IV catheter Correct
• Slow the rate of infusion
• Notify the health care provider
• Check for loose catheter connections
Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be
indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the
catheter. The IV catheter should be removed and a new IV line inserted at a different site.
Slowing the rate of infusion and checking for loose catheter connections are not correct
responses. The health care provider would be notified if phlebitis were to occur, but this is not
the initial action.
2. A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later
the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse.
The IV bag has 100 mL remaining. Which action should the nurse take first?
• Remove the IV
• Sit the client up in bed
• Shut off the IV infusion CorrectlOMoAR cPSD|18634763
• Slow the rate of infusion
Rationale: The client’s symptoms are indicative of speed shock, which results from the rapid
infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused
over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion. Other
actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the
client’s breathing and then immediately notify the health care provider. Slowing the infusion rate
is inappropriate because the client will continue to receive fluid. The IV does not need to be
removed. It may be needed to manage the complication.
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