A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Disconnect the tubing from the catheter.
Remove the IV catheter.
Aspirate the solution from the catheter.
Stop the infusion.
Attach a syringe to the catheter.
The Correct Answer is D,A,E,C,B
The nurse should first stop the infusion (D) to prevent further infiltration of the vesicant solution. Next, the nurse should attach a syringe to the catheter (E) to prepare for aspiration.
Following this, the nurse should aspirate the solution from the catheter (C) to remove as much of the vesicant as possible. After aspiration, the nurse should disconnect the tubing from the catheter (A), ensuring that no additional vesicant is administered. Finally, the nurse should remove the IV catheter (B) to prevent any further exposure to the vesicant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Distal veins, such as those in the hand or forearm of the nondominant arm, are often preferred for initial IV placement. These veins are typically smaller but can be easier to access and cause less discomfort for the patient compared to more proximal veins.
B. Proximal veins, such as those in the upper arm (brachial or basilic veins), may be considered if distal veins are not accessible or suitable. However, proximal veins are larger and can be more difficult to cannulate, potentially causing more discomfort and increasing the risk of complications.
C. The antecubital veins, located in the bend of the elbow, are commonly used for venipuncture due to their accessibility and size. The antecubital vein of the nondominant arm is often preferred to minimize interference with the patient's daily activities and reduce the risk of complications associated with frequent use of the dominant arm.
D. While the antecubital vein of the dominant arm may also be accessible, it is generally recommended to preserve this area for procedures that require a higher level of dexterity and strength. Frequent venipuncture in the dominant arm can lead to discomfort and potential complications, such as phlebitis or thrombosis.
Correct Answer is D
Explanation
D. Muscle weakness is a hallmark sign of hypokalemia. Potassium is crucial for proper muscle contraction, and low levels can impair muscle function. This weakness can affect skeletal muscles (resulting in fatigue, cramps, or generalized weakness) as well as smooth muscles (contributing to constipation or other gastrointestinal symptoms).
A. Hypokalemia is not typically associated with hyperactive bowel sounds.
B. Cerebral edema is not typically associated with hypokalemia. Instead, cerebral edema can occur with conditions such as hyponatremia (low sodium levels) or other metabolic disturbances.
C. Hypokalemia is more commonly associated with hypotension (low blood pressure) rather than hypertension. Low potassium levels can affect vascular smooth muscle tone, potentially leading to vasodilation and hypotension.
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