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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

Colesevelam is a bile acid sequestrant that lowers cholesterol by binding to bile acids in the intestine and preventing their reabsorption into the bloodstream. Some possible explanations for the other choices are:

Choice A. Chlorpromazine is wrong because it is an antipsychotic medication that has no effect on cholesterol levels.

Choice C. Colchicine is wrong because it is an anti-inflammatory drug that is used to treat gout and other inflammatory conditions, not high cholesterol.

Choice D. Cimetidine is wrong because it is a histamine H2 receptor antagonist that reduces stomach acid production and is used to treat ulcers and gastroesophageal reflux disease (GERD), not high cholesterol.

Normal ranges for cholesterol levels vary depending on the type of cholesterol and the risk factors of the individual, but generally, total cholesterol should be less than 200 mg/dL, LDL cholesterol should be less than 100 mg/dL, HDL cholesterol should be more than 40 mg/dL for men and 50 mg/dL for women, and triglycerides should be less than 150 mg/dL.

A. Apply pressure to the IV site. B. Elevate the extremity. C. Slow the infusion rate. D. Flush the IV catheter.

Correct Answer is B

Explanation

This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.

Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.

Pressure can also obstruct blood flow and cause thrombophlebitis.

Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.

Slowing the infusion rate can also delay the delivery of medication or fluid to the client.

Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.

Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.

Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.

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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?