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 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.
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.
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