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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Decrease in protein:
This choice is incorrect. Albumin is a protein found in the blood, and when a client is receiving an infusion of albumin, it is likely to increase, not decrease, the overall protein level in the bloodstream. Albumin infusions are often given to help increase plasma oncotic pressure and improve fluid retention in conditions like shock.
B. Oxygen saturation 96%:
This choice is incorrect. Oxygen saturation of 96% is within the normal range and reflects adequate oxygenation. It doesn't directly relate to the administration of albumin in shock.
C. PaCO2 30 mm Hg:
This choice is incorrect. The partial pressure of carbon dioxide (PaCO2) of 30 mm Hg reflects a respiratory value and doesn't directly relate to the administration of albumin or the management of shock. It's important for assessing acid-base balance, but it's not a specific finding related to the albumin infusion.
D. Increase in BP:
This is the correct choice. Albumin is a colloid solution that helps increase the oncotic pressure within blood vessels, which can contribute to an increase in blood volume. When blood volume increases, it can lead to an increase in blood pressure, which is a desired effect in the management of shock. Increasing blood pressure helps improve perfusion to vital organs and tissues, which is essential in shock situations.

A. Another formulation of potassium should be given IV. B. Potassium chloride should be diluted in dextrose 5% in water. C. The client should be treated by giving potassium by IV bolus. D. The potassium infusion rate is too rapid.

Correct Answer is D

Explanation

A. Another formulation of potassium should be given IV: The type of potassium formulation isn't the issue in this scenario.

B. Potassium chloride should be diluted in dextrose 5% in water: While potassium chloride can be administered in different solutions, the primary concern here is the infusion rate, not the specific diluent.

C. The client should be treated by giving potassium by IV bolus: The concern here is the rate of administration, not the route. Potassium is commonly administered through an IV infusion rather than a bolus due to the risk of cardiac arrhythmias associated with rapid administration.

D. A nurse is caring for a client who is to receive potassium replacement. The nurse should clarify the prescription with the provider because the potassium infusion rate is too rapid.

The prescription indicates that the client should receive potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 minutes. This rate of administration is too fast for potassium replacement and could lead to potentially serious complications, such as hyperkalemia or cardiac arrhythmias. The typical recommended rate for potassium replacement is 10-20 mEq/hour, and this prescription exceeds that range.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in shock and is receiving an infusion of albumin. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who is to receive potassium replacement. The provider's prescription reads, "Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min." For which of the following reasons should the nurse clarify this prescription with the provider?

Correct Answer is D

Explanation

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