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 D

Explanation

A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.

B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.

C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.

D. Decontamination of the client

When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.

A. Excessive scarring B. Blistering from flames C. Blackened dead skin D. A sunburn

Correct Answer is D

Explanation

A. Excessive scarring:

Excessive scarring is not an example of a first-degree burn. It typically occurs in more severe burns that affect deeper layers of the skin, such as second-degree or third-degree burns. Second-degree burns extend into the dermis, while third-degree burns damage all layers of the skin and can lead to significant scarring. First-degree burns, on the other hand, only affect the outer layer of the skin (epidermis) and usually do not result in excessive scarring.

B. Blistering from flames:

Blistering from flames is more characteristic of a second-degree burn rather than a first-degree burn. Second-degree burns involve damage to both the epidermis and part of the dermis, which can result in blister formation. These burns are often caused by direct contact with flames, hot liquids, or steam.

C. Blackened dead skin:

Blackened dead skin is indicative of a third-degree burn, which is the most severe type of burn. Third-degree burns damage all layers of the skin, including the epidermis, dermis, and sometimes underlying tissues. The skin may appear charred or blackened, and these burns often require medical intervention, such as skin grafting, due to the extent of tissue damage.

D. A sunburn:

A sunburn is an example of a first-degree burn. It occurs due to overexposure to ultraviolet (UV) radiation from the sun, leading to redness, pain, and mild swelling of the skin. First-degree burns affect only the outer layer of the skin (epidermis) and typically heal within a few days without significant scarring or blistering. Applying soothing lotions, staying hydrated, and avoiding further sun exposure can help manage sunburns.

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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 is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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