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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?

Initiate a new IV distal to the initial site.

Slow the IV solution rate.

Maintain the extremity below the level of the heart.

Apply a warm, moist compress.

Answer and Explanation

The Correct Answer is D

The most appropriate action for the nurse to take in this situation is:

d. Apply a warm, moist compress.

Here's why the other options are not recommended:

a. Initiate a new IV distal to the initial site: This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
b. Slow the IV solution rate: Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
c. Maintain the extremity below the level of the heart: This action would actually worsen the edema by promoting fluid accumulation at the site.

Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:

Stop the IV infusion.
Assess the extent of the infiltration or extravasation.
Document the findings.
Elevate the affected extremity.
Consult with a physician for further instructions and potential treatment.

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Correct Answer is D

Explanation

This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.

The provider should be informed of this change as soon as possible to prevent further complications.

Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.

While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.

Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.

While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.

Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.

While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.

A. Tinnitus. B. Alopecia. C. Peripheral edema. D. Drowsiness.

Correct Answer is D

Explanation

Drowsiness is a very common adverse effect of paroxetine, a selective serotonin reuptake inhibitor (SSRI) used to treat depression and anxiety. Paroxetine can cause somnolence (sleepiness) in up to 22% of patients who take it. The nurse should instruct the client to monitor for this effect and avoid driving or operating machinery until they know how the medication affects them.

Choice A is wrong because tinnitus (ringing in the ears) is not a common adverse effect of paroxetine.

It may occur rarely in some patients, but it is not a typical symptom of SSRI use.

Choice B is wrong because alopecia (hair loss) is not a common adverse effect of paroxetine.

It may occur rarely in some patients, but it is not a typical symptom of SSRI use.

Choice C is wrong because peripheral edema (swelling of the limbs) is not a common adverse effect of paroxetine.

It may occur rarely in some patients, but it is not a typical symptom of SSRI use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 Ib) since the last visit 2 days ago. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a new prescription for paroxetine. The nurse should instruct the client to monitor for which of the following adverse effects?

Correct Answer is D

Explanation

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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?