Select N Set 2: Pharmacology - NCLEX Practice Questions

The nurse in the medical unit is caring for an 82-year-old female client.

0800:Admitted yesterday with dehydration. 22-gauge peripheral IV catheter in the left forearm, placed yesterday. Site flat, with no redness or swelling. Fluid infusing by pump.

1400:Client reports that the left forearm feels tight and sore. Forearm swollen around the insertion site; skin cool to the touch; clear fluid leaking under the dressing. No redness, warmth or cord along the vein. Right forearm not swollen. Pump running without an alarm.

The nurse has reviewed the Orders from 0800 and the Nurses' Notes from 1400.

Select the 3 actions the nurse should take.

1.Slow the infusion to 25 mL/h.
2.Raise the left arm on a pillow.
3.Flush the catheter with saline.
4.Stop the 0.9% sodium chloride infusion.
5.Remove the catheter from the left forearm.
6.Start a new IV in the left arm below the swelling.