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. Cleansing the injection site is important to reduce the risk of infection.
B. Sterile gloves are not typically required for administering subcutaneous injections unless there is a specific indication, such as when dealing with a client who has a compromised immune system or if there is potential for exposure to bodily fluids.
C. Pinching the skin can help in creating a fold where the needle can be inserted. However, there is no standard recommendation on which hand should be used.
D. Subcutaneous injections are typically administered at a 45-degree or 90-degree angle to the client's skin, depending on the amount of subcutaneous tissue present.
Correct Answer is ["1.5"]
Explanation
Volume to administer (mL) = Dose ordered (mg) / Concentration of drug (mg/mL).
For a dose of 15 mg and a concentration of 10 mg/mL, the calculation would be 15 mg / 10 mg/mL = 1.5 mL.
Therefore, the nurse should administer 1.5 mL of morphine injection.
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