A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

Stop the infusion and remove the IV catheter.

Apply a warm compress to the infusion site.

Notify the provider and obtain an order for a different IV site.

Slow down the infusion rate and monitor the client.

Answer and Explanation

The Correct Answer is A

The nurse should stop the infusion and remove the IV catheter as soon as possible if phlebitis is suspected. Phlebitis is inflammation of a vein that can be caused by mechanical, chemical, or infectious factors. Potassium chloride is a vesicant medication that can cause severe tissue damage if it extravasates into the surrounding tissues.

The nurse should apply a warm compress to the infusion site after removing the IV catheter to reduce inflammation and discomfort. The nurse should notify the provider and obtain an order for a different IV site to continue the infusion of potassium chloride at a different location. The nurse should not slow down the infusion rate and monitor the client because this could worsen the condition and increase the risk of complications.

b) Incorrect. This is an appropriate action after removing the IV catheter, but not before.

c) Incorrect. This is an appropriate action after removing the IV catheter and applying a warm compress, but not before.

d) Incorrect. This is not an appropriate action because it could worsen the condition and increase the risk of complications.

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Correct Answer is A

Explanation

The nurse should notify the provider and document the interaction in the client's chart when a potential medication interaction is identified. The provider may need to adjust or change one or both of the medications to prevent if from harming the client.

A) Correct. This is the appropriate action for the nurse to take when a potential medication interaction is identified.

B) This is not an appropriate action. The nurse should not hold or alter any prescribed medications without consulting with the provider first.

C) This is not an appropriate action. The nurse should not administer both medications as prescribed without notifying the provider of the potential interaction. This could put the client at risk for adverse effects or reduced efficacy of one or both of the medications.

D) This is not an appropriate action. The nurse should not rely on the client's self-report of problems with taking both medications. The client may not be aware of or recognize all of the possible signs and symptoms of a medication interaction.

A. Use the Z-track method to seal the medication in the muscle. B. Aspirate for blood before injecting the medication. C. Massage the injection site after administering the medication. D. Rotate the injection sites among different muscle groups.

Correct Answer is D

Explanation

The nurse should rotate the injection sites among different muscle groups to prevent tissue damage, irritation, and absorption problems. The nurse should follow the recommended sites for intramuscular injections, such as the deltoid, ventrolateral, vastus lateralis, and dorsogluteal muscles.

A) This is not an action to prevent medication errors, but rather an action to prevent leakage of the medication from the injection site and reduce pain and irritation. The Z-track method involves pulling the skin to one side before inserting the needle and releasing it after withdrawing the needle.

B) This is not an action to prevent medication errors, but rather an action to prevent injecting the medication into a blood vessel. Aspiration involves pulling back on the plunger of the syringe before injecting the medication and checking for blood return in the syringe.

C) This is not an action to prevent medication errors, but rather an action to enhance absorption and reduce pain and irritation. Massage involves applying gentle pressure to the injection site after administering the medication.

D) Correct. This is an action to prevent medication errors by avoiding repeated injections in the same muscle group.

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A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's medication list and notices that the client is taking two medications that have a potential interaction. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is administering an intramuscular injection to a client. Which of the following actions should the nurse take to prevent medication errors?

Correct Answer is D

Explanation

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take to ensure medication safety? (Select all that apply.)

A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take first?

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