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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?

A.

Initiate a new IV distal to the initial site.

B.

Slow the IV solution rate.

C.

Maintain the extremity below the level of the heart.

D.

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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Related Questions

Correct Answer is D

Explanation

Drowsiness is a very common adverse effect of paroxetine, a selective serotonin reuptake inhibitor (SSRI) used to treat depression and anxiety. Paroxetine can cause somnolence (sleepiness) in up to 22% of patients who take it. The nurse should instruct the client to monitor for this effect and avoid driving or operating machinery until they know how the medication affects them.

Choice A is wrong because tinnitus (ringing in the ears) is not a common adverse effect of paroxetine.

It may occur rarely in some patients, but it is not a typical symptom of SSRI use.

Choice B is wrong because alopecia (hair loss) is not a common adverse effect of paroxetine.

It may occur rarely in some patients, but it is not a typical symptom of SSRI use.

Choice C is wrong because peripheral edema (swelling of the limbs) is not a common adverse effect of paroxetine.

It may occur rarely in some patients, but it is not a typical symptom of SSRI use.

Correct Answer is A

Explanation

According to various guidelines12345, the recommended rate of intravenous potassium replacement is 10-20 mEq/h with continuous ECG monitoring. The maximum rate is 40 mEq/h in emergency situations. The prescription given by the provider exceeds this limit and could cause cardiac arrhythmias or hyperkalemia.

Choice B is wrong because potassium chloride is a common and appropriate formulation of potassium for intravenous administration.

Choice C is wrong because potassium chloride should not be diluted in dextrose 5% in water, as this could cause hyperglycemia or osmotic diuresis.

Choice D is wrong because potassium should never be given by IV bolus, as this could cause cardiac arrest or tissue necrosis.

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