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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 B

Explanation

Carbamazepine is an anticonvulsant medication that is used to treat seizures and nerve pain. It works by reducing the activity of certain nerve cells in the brain.

Choice A is wrong because beclomethasone is a corticosteroid that is used to treat asthma and allergic rhinitis. It does not interact with carbamazepine.

Choice B is correct because the estrogen-progestin combination is a hormonal contraceptive that is used to prevent pregnancy and regulate menstrual cycles. It interacts with carbamazepine because carbamazepine can increase the breakdown of estrogen and progestin in the body, making them less effective. The nurse should instruct the client to use an alternative or additional method of birth control while taking carbamazepine.

Choice C is wrong because diphenhydramine is an antihistamine that is used to treat allergies, motion sickness, and insomnia. It does not interact with carbamazepine.

Choice D is wrong because the nicotine transdermal system is a nicotine replacement therapy that is used to help people quit smoking. It does not interact with carbamazepine.

A. Improved cognition. B. Cardiac arrhythmias absent. C. Decreased vomiting. D. Absent Chvostek’s sign.

Correct Answer is A

Explanation

Hyponatremia is a condition where the sodium level in the blood is too low, which can cause confusion, lethargy, seizures, and coma. A hypertonic solution is a fluid that has a higher concentration of solutes than the blood, which can help raise the sodium level and reduce the brain swelling caused by hyponatremia. Therefore, improved cognition indicates that the treatment is effective.

Choice B. Cardiac arrhythmias absent.

Cardiac arrhythmias are not a common symptom of hyponatremia unless it is severe or rapid in onset.

Therefore, their absence does not necessarily indicate that the treatment is effective.

Choice C. Decreased vomiting.

Vomiting can be a cause or a consequence of hyponatremia, depending on the underlying condition.

Decreased vomiting may indicate that the patient is less nauseated, but it does not reflect the sodium level or the brain status.

Choice D. Absent Chvostek’s sign.

Chvostek’s sign is a facial twitching that occurs when tapping on the cheek, which indicates hypocalcemia (low calcium level).

It is not related to hyponatremia or hypertonic solution.

Normal ranges for sodium are 135 to 145 mEq/L and for calcium are 8.5 to 10.5 mg/dL.

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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

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A nurse is reviewing the list of current medications for a client who is to start a new prescription for carbamazepine. The nurse should identify which of the following medications interacts with carbamazepine?

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Explanation

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Correct Answer is A

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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?