A client, who is receiving intravenous chemotherapy into a peripheral vein, says that the arm burns terribly in and around the intravenous site. What is the nurse's best first action?
Slow the rate of infusion
Apply a warm compress to the site
Discontinue the infusion
Check for blood return
The Correct Answer is C
A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.
Correct Answer is ["62.5"]
Explanation
To determine the IV pump rate, we need to calculate the flow rate in milliliters per hour (mL/h).
Given:
- Total volume: 500 mL
- Infusion time: 8 hours
Calculation:
- Flow rate = Total volume / Infusion time
- Flow rate = 500 mL / 8 hours
- Flow rate = 62.5 mL/h
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