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
The correct sequence for mixing regular insulin and NPH insulin in the same syringe is important to ensure proper dosing. The nurse should follow these steps:
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Inject air into the NPH (intermediate-acting) insulin vial: Injecting air into the NPH vial first helps to equalize the pressure in the vial, making it easier to withdraw the insulin later. This step is done first to avoid contaminating the regular insulin vial with NPH insulin.
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Inject air into the regular insulin vial: Next, inject an amount of air equal to the intended regular insulin dose into the regular insulin vial.This also helps to equalize the pressure and makes it easier to withdraw the insulin.
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Withdraw the regular insulin from the vial: The nurse should withdraw the regular insulin first because it is clear and not contaminated. This prevents any NPH insulin from mixing into the regular insulin vial.
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Withdraw the regular insulin from the vial: Finally, the nurse withdraws the NPH insulin. Since the regular insulin has already been drawn up, there is no risk of contaminating the regular insulin with NPH insulin.
This sequence ensures that you don't contaminate the vials, and you accurately withdraw the appropriate doses of each insulin type.
Correct Answer is B
Explanation
Hot flashes are a common side effect of tamoxifen, which is hormone therapy for breast cancer that blocks the action of estrogen.
Tamoxifen can cause menopause-like symptoms in women, such as irregular or missing periods, vaginal discharge or bleeding, and mood changes. Choice A is wrong because tinnitus (ringing in the ears) is not a known side effect of tamoxifen.
Choice C is wrong because urinary frequency (needing to urinate more often) is not a known side effect of tamoxifen.
Choice D is wrong because constipation (difficulty passing stools) is not a known side effect of tamoxifen.
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