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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

a.While weight changes can be concerning, they are not typically life-threatening and can occur as a common side effect of antidepressants, including citalopram. Monitoring is important, but it does not require immediate reporting.

b.This is the priority to report because confusion can indicate a serious reaction to the medication, such as serotonin syndrome, especially if it occurs in conjunction with other symptoms like agitation, hallucinations, or rapid heart rate. Confusion can also signal worsening mental status, which is critical for someone with major depression.

c.This refers to teeth grinding, which can occur with certain antidepressants. While it should be monitored and possibly addressed with interventions, it is generally not an immediate concern compared to confusion.

d.Sleep disturbances can be a side effect of citalopram and may need adjustment of treatment or recommendations for sleep hygiene, but they are not as urgent as confusion.

A. The client has a BUN level of 18 mg/dL. B. The client reports a history of nausea with cefuroxime. C. The client has a history of a severe penicillin allergy. D. The client takes an aspirin daily.

Correct Answer is C

Explanation

This is the priority for the nurse to report to the provider because cefuroxime is a cephalosporin antibiotic that can cause serious or life-threatening allergic reactions in people who are allergic to penicillin. The nurse should not administer cefuroxime to this client until the provider is notified and an alternative antibiotic is prescribed.

Choice A is wrong because the client has a BUN level of 18 mg/dL, which is within the normal range of 7 to 20 mg/dL.

This does not indicate any renal impairment or adverse reaction to cefuroxime.

Choice B is wrong because the client reports a history of nausea with cefuroxime, which is a common side effect of this drug.

The nurse should instruct the client to take cefuroxime with food to reduce nausea, but this is not a priority to report to the provider.

Choice D is wrong because the client takes aspirin daily, which does not interact with cefuroxime.

The nurse should monitor the client for any signs of bleeding or bruising while taking aspirin, but this is not a priority to report to the provider.

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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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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?