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 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.
Correct Answer is D
Explanation
D Excessive use of bisacodyl or other laxatives can indeed cause these adverse effects. Rectal burning can occur due to irritation from frequent bowel movements, while dehydration and electrolyte imbalance can result from fluid loss caused by frequent laxative use.
A. While regular bowel movements are important for many individuals, daily bowel movements are not necessary for everyone and can vary depending on diet, hydration, and individual health conditions.
B. Bisacodyl is a stimulant laxative used for short-term relief of constipation. It does not interact with dietary fiber intake, nor should the client necessarily decrease high-fiber foods unless specifically advised by their healthcare provider for other reasons.
C. Chronic use of bisacodyl, a stimulant laxative, can indeed lead to dependence and potentially harmful effects on the body's water and salt balance
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