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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

The client will need to have blood levels drawn to monitor the therapeutic and toxic levels of theophylline, a bronchodilator that is used to treat symptoms of asthma and other lung conditions. The normal range of theophylline in the blood is 10 to 20 mcg/mL.

Choice A is wrong because the client should not sprinkle the medication in applesauce or any other food. Theophylline is a sustained-release capsule that should be swallowed whole and not crushed or chewed.

Choice B is wrong because the client should avoid caffeine while on this medication, as it can increase the side effects of theophylline, such as nausea, vomiting, headache, and irregular heart rate.

Choice C is wrong because the client should not limit fluid intake while on this medication unless instructed by the doctor.

Fluid intake helps prevent dehydration and kidney problems that can affect theophylline levels in the blood.

A. A client who has a referral for social services. B. A client who is transported to radiology. C. A client who is transferred to a step-down unit. D. A client who has a consultation for physical therapy.

Correct Answer is C

Explanation

Medication reconciliation is the process of creating the most accurate list possible of all medications a client is taking and comparing that list against the physician’s orders at every transition of care. A client who is transferred to a step-down unit is at risk of medication errors due to changes in the level of care and the prescribing providers. Therefore, medication reconciliation should be performed for this client to prevent adverse drug events.

Choice A is wrong because a referral for social services does not involve a change in the client’s medications or care setting.

Choice B is wrong because transport to radiology is a temporary and short-term movement that does not require medication reconciliation.

Choice D is wrong because a consultation for physical therapy does not affect the client’s medication regimen or orders.

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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 D

Explanation

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Correct Answer is C

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?