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 B
Explanation
B. Dextrose 10% in water is a solution that contains a high concentration of glucose (dextrose). Infusing D10W can lead to an increase in blood glucose levels, especially if the client's body cannot metabolize the glucose effectively (e.g., in diabetic patients or those with impaired glucose tolerance).
A. Dextrose 10% in water does not contain calcium. Hypercalcemia refers to elevated calcium levels in the blood, which can occur due to various causes such as hyperparathyroidism or excessive vitamin D intake, but not from D10W infusion.
C. Dextrose 10% in water is not used to treat hypovolemia (low blood volume). It is a solution primarily used to provide calories and prevent ketosis rather than to expand circulating blood volume.
D. Dextrose 10% in water does not contain potassium. Hypokalemia (low potassium levels) can occur due to various reasons such as diuretic use, gastrointestinal losses, or inadequate intake, but it is not directly related to D10W infusion.
Correct Answer is ["D","E"]
Explanation
D. Persistent headache can occur with elevated levels of gentamicin, as it may indicate neurotoxicity. Gentamicin can cause neurotoxic effects, including headaches, especially when levels are elevated.
E. Tinnitus (ringing in the ears) is a classic symptom of gentamicin toxicity. Elevated gentamicin levels can lead to ototoxicity, which manifests as tinnitus among other auditory symptoms.
A. Insomnia is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause insomnia.
B. Constipation is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause constipation.
C. Xerostomia (dry mouth) is not typically associated with elevated levels of gentamicin. Elevated gentamicin levels are not known to cause xerostomia.
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