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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The nurse should check the medication label against the MAR three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.
The nurse should also ask the client to state their name and date of birth and use a barcode scanner to verify the client's identification band and the medication. These are methods of ensuring that the right medication is given to the right client.
The nurse should follow the six rights of medication administration: right client, right medication, right dose, right route, right time, and right documentation.
The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.
a) Correct. This is one of the methods of ensuring medication safety.
b) Correct. This is another method of ensuring medication safety.
c) Correct. This is a third method of ensuring medication safety.
d) Incorrect. The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.
e) Correct. This is a general principle of medication safety.
Correct Answer is A
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.