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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 A

Explanation

This is because it uses the full name of the drug, the exact dose, the route of administration, the frequency, and the indication for use. It also avoids any abbreviations that could be confused with other drugs or measurements.

Choice B is wrong because MS is an abbreviation for morphine sulfate which could be mistaken for magnesium sulfate.

Choice C is wrong because MSO4 is an abbreviation for morphine sulfate that could be mistaken for magnesium sulfate.

Choice D is wrong because 6.0 mg could be misread as 60 mg and lead to a tenfold overdose.

Normal ranges for morphine dosage depend on the route of administration, the indication, and the patient’s tolerance and response.

For acute pain, the usual oral dose is 10 to 30 mg every 4 hours as needed. For chronic pain, the usual oral dose is 15 to 30 mg every 8 to 12 hours as needed.

For intravenous (IV) administration, the usual dose is 2.5 to 15 mg every 4 hours as needed.

The morphine equivalent daily dose (MEDD) is a concept that attempts to establish an equivalency in terms of dose when comparing any opioid to morphine.

A. Rinse your child’s mouth following administration. B. A spacer will make it easier to use the device. C. Soak the inhaler in water after use. D. Have your child take one inhalation as needed for shortness of breath. E. Shake the device prior to administration.

Correct Answer is ["A","B"]

Explanation

Fluticasone is an inhaled steroid that prevents the symptoms of asthma by decreasing inflammation in the airways. It is not used to treat a sudden asthma attack.

Some additional information to explain why the other choices are wrong are:

Choice C is wrong because soaking the inhaler in water after use can damage the device and affect its performance.

Choice D is wrong because fluticasone is not a rescue inhaler that can be used as needed for shortness of breath.It is a controller inhaler that should be used regularly as prescribed by the doctor.

Choice E is wrong because shaking the device prior to administration is not necessary for a fluticasone metered-dose inhaler (MDI).However, it is recommended for fluticasone inhalation powder (Flovent Diskus). Some normal ranges that may be applicable are:

The usual dose of fluticasone MDI for adults and children 12 years and older is 55 to 232 mcg twice a day.The usual dose of fluticasone MDI for children 4 to 11 years old is 30 mcg twice a day. The maximum dose of fluticasone MDI for adults and children 12 years and older is 1000 mcg twice a day.

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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

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Correct Answer is A

Explanation

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Correct Answer is ["A","B"]

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?