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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Calcium gluconate is used to treat hypermagnesemia because it can help calm some symptoms such as impaired breathing, irregular heartbeat, and hypotension. Calcium also helps normalize the neuromuscular function that is affected by excess magnesium.
Choice B. Acetylcysteine is wrong because it is used to treat acetaminophen overdose and prevent kidney damage from contrast dye.
It has no role in treating hypermagnesemia.
Choice C. Flumazenil is wrong because it is used to reverse the effects of benzodiazepines, a class of sedative drugs.
It has no role in treating hypermagnesemia.
Choice D. Protamine sulfate is wrong because it is used to reverse the effects of heparin, an anticoagulant drug.
It has no role in treating hypermagnesemia.
Normal ranges for magnesium are 1.7 to 2.3 mg/dL or 0.7 to 1.1 mmol/L. Hypermagnesemia is defined as a magnesium level above 2.6 mg/dL or 1.5 mmol/L.
Correct Answer is A
Explanation
The client should stay upright for at least 15 minutes after taking ferrous gluconate to prevent oesophagal irritation. Choice B is wrong because taking an antacid with ferrous gluconate can decrease its absorption and effectiveness.
Choice C is wrong because taking ferrous gluconate with milk can also reduce its absorption and cause gastrointestinal distress.
Choice D is wrong because black stools are a common and harmless side effect of ferrous gluconate and do not indicate a need to notify the provider. Ferrous gluconate is an iron supplement used to treat or prevent iron deficiency anaemia, a condition where the body does not have enough red blood cells to carry oxygen to the tissues.
Iron is an essential component of haemoglobin, the protein that carries oxygen in the blood.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.