Author Question: The nurse assesses the patient's IV insertion site and observes that the vein is hard, the skin is ... (Read 109 times)

Tazate · **on:** Jun 25, 2018

The nurse assesses the patient's IV insertion site and observes that the vein is hard, the skin is red and tender, and a blood return in the IV line. After removing the IV catheter, which action should the nurse take next?

a. Obtain an arm board to properly secure the IV.
b. Elevate the arm above the level of the heart.
c. Clean the site with alcohol and apply cool compresses.
d. Apply a warm moist pack.

Question 2

The nurse is caring for a patient with flaccid paralysis after sustaining a spinal cord injury 3 days earlier. The family excitedly notifies the nurse that the patient has flexed his arm. Which response is best for the nurse to make?

a. I will give the doctor this wonderful news.
b. Avoid directly touching the arm muscles so that you don't cause more muscle spasms.
c. This movement means that the spinal cord is adjusting to the injury.
d. These muscles spasms are a type of in-voluntary movement that happens fre-quently in patients with spinal cord inju-ries.

IRincones · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

D
These are signs and symptoms of phlebitis and should be treated with a warm moist pack to in-crease blood flow to the area. The IV has been discontinued, so an arm board for stabilization is unnecessary. Elevation of the arm would be helpful to reduce swelling. A cool compress would be indicated for other issues related to IV infusion problems, such as extravasation.

Answer to Question 2

D
The patient is experiencing the spastic phases of paralysis that occurs as the cord adjusts to injury. The family members may interpret these spasms as a return of voluntary limb function and an indicator of impending complete recovery. First, the nurse should explain that this movement is not purposeful and an expected finding that often occurs in patients with spinal cord injuries. The nurse should not describe this finding as wonderful news. While it is important to avoid sti-mulating spasms when moving the patient and the technique involves avoiding direct contact with the muscles, the family could misunderstand the nurse's teaching as an accusation that someone's touch caused this movement. While the spinal cord is adjusting to injury, this state-ment is vague enough that the family may not realize that the movement is not purposeful.