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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. 0.9% sodium chloride (normal saline) is isotonic, meaning it has the same concentration of solutes as blood plasma. It is used to expand intravascular volume and replace fluids and electrolytes.

B. "Hypnotic" refers to medications that induce sleep and has no relevance to IV solutions. This term does not apply to IV solutions.

C. A hypotonic solution has a lower concentration of solutes compared to normal body fluids. Examples include 0.45% sodium chloride (half-normal saline) or 5% dextrose in water (D5W). 0.9% sodium chloride (normal saline) is not hypotonic; rather, it is isotonic.

D. A hypertonic solution has a higher concentration of solutes compared to normal body fluids. Examples include 3% sodium chloride or 5% dextrose in 0.9% sodium chloride. 0.9% sodium chloride (normal saline) is not hypertonic; rather, it is isotonic.

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.

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Naxlex Comprehensive Predictor Exams

A patient has been admitted to the postsurgical nursing unit after surgery. The health care provider has ordered the patient to have an IV of 0.9 sodium chloride. The nurse who is caring for the patient recognizes this as what type of solution?

Correct Answer is A

Explanation

Correct Answer is ["50"]

Explanation

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