A nurse is assisting with the care of a client who has pneumonia.
For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Administer phytonadione.
Apply cool compress to the extremity.
Elevate extremity.
Suggest irrigating the IV catheter
Assist in inserting a new IV catheter in a site distal to infiltration site
Send the catheter tip for culture.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}
Administer phytonadione (Vitamin K): Contraindicated
There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.
Apply cool compress to the extremity: Anticipated
A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.
Elevate extremity: Anticipated
Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.
Suggest irrigating the IV catheter: Contraindicated
Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.
Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated
A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.
Send the catheter tip for culture: Anticipated
Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Impetigo contagiosa: Impetigo contagiosa is a bacterial skin infection caused by either Staphylococcus aureus or Streptococcus pyogenes. While it is contagious, it is not typically required to be reported to the state health department, as it is not considered a high-priority communicable disease that mandates immediate reporting.
B) Sarcoptes scabiei: Scabies, caused by the mite Sarcoptes scabiei, is a contagious parasitic skin infection. Although scabies can be easily spread, it is generally not a reportable disease to the state health department unless there is an outbreak in a specific setting, such as a healthcare facility or school.
C) Neisseria gonorrhoeae: Neisseria gonorrhoeae, the bacterium that causes gonorrhea, is a sexually transmitted infection (STI) that is required by law to be reported to the state health department. Gonorrhea is a notifiable disease because of its potential for rapid transmission, complications, and its increasing resistance to antibiotics. Early reporting helps control the spread and provides opportunities for public health interventions.
D) Human papillomavirus (HPV): Human papillomavirus (HPV) is a viral infection that is not required to be reported to the state health department. While HPV is the most common STI and can lead to cancers such as cervical cancer, it is not mandated for reporting as an individual infection. However, certain types of HPV-related cancers may be tracked through cancer registries.
Correct Answer is D
Explanation
A) Administer aspirin for pain: Aspirin is an anticoagulant and should be avoided in clients receiving other anticoagulant therapy, especially in the context of deep vein thrombosis (DVT). Using aspirin could increase the risk of bleeding and complications. Therefore, it is not appropriate for pain management in this situation.
B) Initiate bed rest: While rest may be indicated for comfort and to reduce the risk of further clot formation, complete bed rest is generally not recommended in the management of DVT unless specifically directed by the healthcare provider. Early ambulation and the use of compression devices or stockings are typically encouraged to promote circulation and reduce the risk of complications, such as pulmonary embolism.
C) Massage the affected extremity every 4 hr: Massaging the affected extremity is contraindicated in a client with DVT, as it can dislodge the clot and increase the risk of a pulmonary embolism or other complications. It is important to avoid any direct manipulation of the affected limb to prevent causing harm.
D) Apply an ice pack to the affected extremity for 20 min every 2 hr: Applying an ice pack is
an appropriate intervention for reducing swelling and providing comfort in the case of a DVT. The cold therapy helps to constrict blood vessels, reduce inflammation, and relieve pain. This intervention should be done carefully to avoid skin damage, and the nurse should monitor the skin for signs of injury.
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