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 ["50"]
Explanation
To calculate the flow rate in gtt/min, the total volume (400 mL) should be divided by the total time in minutes (8 hours x 60 minutes/hour = 480 minutes). This gives the mL/min.
Then, multiply the mL/min by the drop factor (60 gtt/mL) to get the gtt/min. So, the calculation would be (400 mL / 480 min) x 60 gtt/mL = 50 gtt/min.
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is C
Explanation
C. This method is recommended because it is less painful, as the sides of the fingertips have fewer nerve endings compared to the pads or 'balls' of the fingers.
A. Avoiding the use of the thumbs is not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
B. Avoiding the use of the dominant hand's fingers are not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
D. Using the ball of the finger is not recommended for blood glucose monitoring because it can be more painful and may lead to less blood flow, resulting in difficulty obtaining an adequate blood sample.
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