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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

Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that is used to treat high blood pressure and heart failure. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart. However, one of the common side effects of lisinopril is hypotension, which means low blood pressure. Hypotension can cause dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position. Therefore, the nurse should monitor the client’s blood pressure when administering lisinopril and report any signs of hypotension to the doctor.

Choice A is wrong because tinnitus, which means ringing or buzzing in the ears, is not a common or serious side effect of lisinopril.

Tinnitus can be caused by other factors such as ear infections, loud noises, or medications such as aspirin or antibiotics.

Choice C is wrong because hypokalemia, which means low potassium levels in the blood, is not a common or serious side effect of lisinopril. In fact, lisinopril can cause hyperkalemia, which means high potassium levels in the blood, especially in patients with kidney problems or diabetes. Hyperkalemia can cause irregular heartbeats, muscle weakness, or numbness. Therefore, the nurse should monitor the client’s potassium levels when administering lisinopril and avoid giving potassium supplements or salt substitutes that contain potassium.

Choice D is wrong because bradycardia, which means slow heart rate, is not a common or serious side effect of lisinopril.

Lisinopril does not affect the heart rate directly, but it can lower the blood pressure and improve the heart function.

Bradycardia can be caused by other factors such as heart block, sinus node dysfunction, or medications such as beta blockers or calcium channel blockers.

A. Pallor. B. Bradycardia. C. Urticaria. D. Dyspepsia.

Correct Answer is C

Explanation

Urticaria, also known as hives, is a common sign of an allergic reaction to penicillin. An allergic reaction is an abnormal response of the immune system to the drug. Other signs and symptoms of penicillin allergy may include skin rash, itching, fever, swelling, shortness of breath, wheezing, runny nose, itchy eyes, and anaphylaxis. Anaphylaxis is a rare but life-threatening condition that affects multiple body systems and requires immediate emergency treatment.

Choice A is wrong because pallor is not a typical sign of an allergic reaction to penicillin.

Pallor means pale skin and may be caused by other conditions such as anemia or shock.

Choice B is wrong because bradycardia is not a typical sign of an allergic reaction to penicillin.

Bradycardia means slow heart rate and may be caused by other conditions such as heart block or medication side effects.

Choice D is wrong because dyspepsia is not a typical sign of an allergic reaction to penicillin.

Dyspepsia means indigestion and may be caused by other conditions such as gastritis or peptic ulcer.

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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?