Practice Quiz

Nurse Aide NNAAP Exam Prep

Category - NNAAP

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While you are obtaining a client’s vital signs, he tells you that he is experiencing pain on his IV site. You check his right arm where the intravenous line is connected and notice that it is reddened. What should be your priority action?
  1. Change the position of the clamp.
  2. Regulate the flow rate to facilitate flushing.
  3. Report the observation immediately to the licensed nurse.
  4. Stop the flow rate, pull out the IV line aseptically, and report to the licensed nurse. This is a sign of phlebitis.
Explanation
Answer: C -As a nurse assistant, you help meet the safety, hygiene, and activity needs of persons with IVs. You are never responsible for maintaining IV therapy. Nor do you regulate the flow rate or change IV bags. You never give blood or IV drugs. Follow the nurse’s directions and care plan. Other signs and symptoms of IV complications that you need to report to the licensed nurse are:


§Bleeding
§Puffiness or swelling
§Pale skin
§Hot or cold skin near the site
§Fever itching
§Drop in blood pressure
§Pulse rate greater than 100 beats per minute
§Cyanosis
§Changes in mental function
§Difficulty breathing
§Shortness of breath
§Decreasing or no urine output
§Chest pain
§Nausea
§Confusion
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