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 A
Explanation
A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).
This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.
B. The blood will be held, and the health care provider will be notified.
This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.
C. The transfusion will begin after the administration of an antihistamine.
Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.
D. The transfusion will begin as prescribed.
This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.
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