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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Change the dressing when it is saturated:

This intervention is the most appropriate for managing a deep wound with a wet to-damp dressing. Wet to-damp dressings are designed to maintain a moist environment conducive to wound healing. Changing the dressing when it becomes saturated with wound exudate helps prevent excessive moisture accumulation, which can lead to skin maceration and potential infection. It ensures that the wound bed remains in an optimal healing environment and reduces the risk of complications.

B. Assess the wound bed once a day:

Assessing the wound bed is an essential part of wound care, as it allows the nurse to monitor healing progress, assess for signs of infection, and evaluate the effectiveness of the chosen dressing. However, the frequency of wound bed assessment may vary depending on the specific patient's needs and the type of dressing being used. While daily assessment is generally recommended, it does not directly dictate the timing of dressing changes for wet to-damp dressings, which are primarily changed based on saturation levels.

C. Contact the provider when the dressing leaks:

Contacting the provider when the dressing leaks or when there are concerns or complications is an important step in patient care. Leaking dressings can indicate issues with the dressing application, excessive wound exudate, or potential complications such as infection. It's crucial to inform the provider promptly so that appropriate interventions can be implemented, but this instruction is more reactive and does not specifically address the timing of dressing changes.

D. Change the dressing every 6 hours:

Changing the dressing every 6 hours is not typically recommended for wet to-damp dressings unless specifically indicated based on the patient's condition and the amount of wound exudate. Frequent dressing changes can disrupt the healing process, cause unnecessary trauma to the wound bed, and increase the risk of infection. Dressing change frequency should be based on the assessment of wound exudate and the dressing's ability to maintain a moist environment.

A. Healthy middle-aged adult who never had chickenpox B. Older adult who lakes large doses of prednisone for a chronic condition C. Middle-aged adult who just started taking chemotherapy D. Nurse who recently received the first dose of varicella vaccine E. Young adult who is positive for the human immunodeficiency virus (HIV):

Correct Answer is ["B","C","E"]

Explanation

A. Healthy middle-aged adult who never had chickenpox:

This individual has not had chickenpox, which means they are susceptible to varicella-zoster virus (VZV) infection. If they contract herpes zoster (shingles), they are at risk for complications, although typically healthy adults are less likely to experience severe complications compared to immunocompromised individuals or older adults.

B. Older adult who takes large doses of prednisone for a chronic condition:

Chronic corticosteroid use, such as prednisone, can suppress the immune system and increase the risk of herpes zoster infection. Additionally, if herpes zoster develops in an older adult, they are at higher risk for complications such as postherpetic neuralgia (persistent nerve pain), bacterial superinfection of the rash, and dissemination of the virus.

C. Middle-aged adult who just started taking chemotherapy:

Chemotherapy suppresses the immune system, making individuals more susceptible to infections. If a person undergoing chemotherapy develops herpes zoster, they are at increased risk for serious complications due to their weakened immune response.

D. Nurse who recently received the first dose of varicella vaccine:

The varicella vaccine is designed to prevent chickenpox and reduce the risk of herpes zoster (shingles) in vaccinated individuals. Therefore, a nurse who received the varicella vaccine is less likely to experience serious complications from herpes zoster infection compared to those who are unvaccinated.

E. Young adult who is positive for the human immunodeficiency virus (HIV):

Individuals with HIV have a weakened immune system, increasing their susceptibility to infections, including herpes zoster. Moreover, herpes zoster in HIV-positive individuals can be more severe, prolonged, and may lead to complications such as disseminated herpes zoster, involving multiple organs and potentially becoming life-threatening.

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A nurse assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

Correct Answer is A

Explanation

Which people have the greatest risk for serious complications secondary to herpes zoster infection? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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