A nurse assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?
Stop the infusion of IV fluids
Apply cold compresses to the IV site
Elevate the extremity on a pillow
Flush the catheter with normal saline
The Correct Answer is A
A. Stop the infusion of IV fluids:
This action may be appropriate if there are signs of infiltration or extravasation, where the IV fluid leaks into the surrounding tissue instead of entering the vein. Stopping the infusion can help prevent further tissue damage and assess the extent of the infiltration.
B. Apply cold compresses to the IV site:
Cold compresses can help reduce swelling and discomfort at the IV site. This action may be appropriate if there are signs of local inflammation or mild irritation at the insertion site.
C. Elevate the extremity on a pillow:
Elevating the extremity can help reduce swelling and promote venous return. This action is beneficial if there is edema or localized swelling above the IV site.
D. Flush the catheter with normal saline:
Flushing the catheter with normal saline is not typically the initial action in response to edema and tenderness above the IV site. Flushing is more commonly performed to ensure patency and proper functioning of the IV catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Body mass index (BMI) of 19:
A BMI of 19 falls within the normal weight range. While obesity (high BMI) is a known risk factor for surgical complications, including SSIs, having a lower BMI (underweight) like 19 may not directly increase the risk of SSIs. However, extreme malnutrition or low BMI due to underlying health conditions could potentially impact wound healing and immune function, indirectly contributing to infection risk.
B. History of deep vein thrombosis (DVT):
A history of deep vein thrombosis is a risk factor for surgical complications, including SSIs. Patients with a history of DVT may have impaired circulation or underlying vascular issues, which can affect tissue perfusion, wound healing, and increase the risk of infections.
C. Aged 55 years old:
Age is a risk factor for surgical complications, including SSIs. Older adults, typically defined as those aged 65 and above, may have reduced immune function, slower wound healing, and underlying health conditions that contribute to infection risk. While 55 years old is not considered advanced age in terms of surgical risk, older age in general is associated with a higher risk of complications.
D. Type 2 diabetes mellitus:
Type 2 diabetes mellitus is a significant risk factor for SSIs. Diabetes can impair immune function, delay wound healing, and increase susceptibility to infections. Poorly controlled blood sugar levels in diabetic patients can further exacerbate the risk of SSIs post-surgery.
Correct Answer is B
Explanation
A. Loose connective tissue:
Melanocytes are not typically found in loose connective tissue. Their primary location is within the epidermis, specifically in the basal layer, where they interact with keratinocytes to produce melanin and contribute to skin color. Loose connective tissue contains collagen and elastin fibers, as well as fibroblasts, but it does not house melanocytes.
B. Epidermis:
This is the correct answer. Melanocytes are primarily located in the basal layer of the epidermis, which is the deepest layer of the epidermis. These cells produce melanin, a pigment that helps protect the skin from UV radiation and determines skin color. Melanocytes are interspersed among keratinocytes in the epidermis and transfer melanin to keratinocytes to provide skin pigmentation.
C. Dermis:
The dermis is the layer of skin beneath the epidermis and consists of connective tissue, blood vessels, nerves, hair follicles, and sweat glands. While the dermis plays a crucial role in supporting and nourishing the epidermis, melanocytes are not primarily located in the dermis. They are confined to the basal layer of the epidermis.
D. Superficial fascia:
The superficial fascia, also known as the subcutaneous tissue or hypodermis, lies beneath the dermis and consists of adipose (fat) tissue and connective tissue. It provides insulation, energy storage, and cushioning for underlying structures. However, melanocytes are not typically found in the superficial fascia. They are restricted to the epidermis, specifically the basal layer, where they carry out their function of melanin production.
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