A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?
Apply a warm, moist compress.
Slow the IV solution rate.
Initiate a new IV distal to the initial site.
Maintain the extremity below the level of the heart
The Correct Answer is A
A. Apply a warm, moist compress.
Explanation:
A cool and edematous IV infusion site could indicate infiltration of the IV site, which occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream. Applying a warm, moist compress to the site can help improve blood circulation and reduce the discomfort associated with infiltration. This action can also help reduce tissue damage.
B. Slow the IV solution rate: Slowing the IV solution rate might not be effective in resolving the infiltration. It's important to address the infiltration itself rather than just adjusting the rate of infusion.
C. Initiate a new IV distal to the initial site: While starting a new IV site might be necessary if the current site cannot be salvaged, it's not the initial action to take. Applying warm, moist compresses and assessing the severity of the infiltration are appropriate steps before considering a new IV site.
D. Maintain the extremity below the level of the heart: Elevating the extremity could help reduce swelling in some cases, but it's not the primary action to take when dealing with IV infiltration.
Remember, prompt assessment and appropriate interventions are essential to prevent complications associated with IV infiltration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use a gravity flow set:
Incorrect Explanation: Using a gravity flow set is not appropriate for administering amphotericin B lipid complex.
Explanation: Amphotericin B lipid complex is typically administered using a dedicated infusion pump to ensure accurate control over the infusion rate and to prevent potential complications.
B. Discard the medication if it is yellow:
Incorrect Explanation: Discarding the medication solely based on its color may not be accurate for the amphotericin B lipid complex.
Explanation: Amphotericin B lipid complex may appear yellowish, and the color itself is not necessarily an indication of its potency or stability. It's important to follow specific guidelines provided by the pharmacy or manufacturer for assessing the integrity of the medication.
C. Prime the tubing with 0.9% sodium chloride:
Correct Answer: Priming the tubing with 0.9% sodium chloride is the appropriate action to ensure the medication is properly administered.
Explanation: Priming the tubing with a compatible solution, such as 0.9% sodium chloride, helps prevent the medication from adhering to the tubing and ensures that the full dose reaches the client.
D. Administer the medication over 2 hr:
Incorrect Explanation: Administering amphotericin B lipid complex over 2 hours is not the standard infusion time.
Explanation: Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. However, the specific infusion rate and duration may vary based on the client's condition and the healthcare provider's orders.
Correct Answer is B
Explanation
A. "Plan to self-administer this medication for the next 6 months": The duration of treatment may vary based on individual circumstances and medical evaluation. It's not appropriate to make a blanket statement about the treatment duration.
B. "Administer the medication into one nostril once per week."
Cyanocobalamin is a form of vitamin B12 that is used to treat pernicious anemia. It can be administered via nasal spray in some cases. The appropriate dosing for nasal cyanocobalamin usually involves administration once a week. The client should be instructed to administer the medication into one nostril as directed by their healthcare provider.
C. "Lie down for 1 hour after administering the medication": There is no need for the client to lie down for an extended period after administering nasal cyanocobalamin.
D. "Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose": This is not a standard recommendation for administering nasal cyanocobalamin. The client should follow the specific instructions provided by their healthcare provider.
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