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.
Elevate extremity
Send the catheter tip for culture.
Assist in inserting a new IV catheter in a site distal to infiltration site.
Suggest irrigating the IV catheter.
Apply a cool compress to the extremity.
Administer phytonadione.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
Elevate extremity. Anticipated. This helps to reduce swelling and improve blood flow to the affected area. Send the catheter tip for culture. Anticipated. This helps to identify the possible cause of infection and guide the appropriate antibiotic therapy.
Assist in inserting a new IV catheter in a site distal to infiltration site. Contraindicated. A new IV catheter should be inserted in a site proximal to the infiltration site or in another extremity to avoid further damage to the infiltrated vein.
Suggest irrigating the IV catheter. Contraindicated. Irrigating the IV catheter may worsen the infiltration and increase the risk of complications.
Apply a cool compress to the extremity. Anticipated. This helps to reduce inflammation and pain at the infiltration site.
Administer phytonadione. Contraindicated.Phytonadione is a vitamin K antagonist that is used to reverse the effects of warfarin, an anticoagulant. It has no role in the management of IV infiltration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Fever. Fever is not an adverse effect of hypoglycemia. Fever is usually associated with an elevated body temperature, often due to infection or other inflammatory conditions, and is not directly related to low blood sugar levels.
Choice B rationale:
Shakiness. Shakiness is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body responds with symptoms like trembling or shakiness, which is caused by the release of stress hormones like epinephrine. These symptoms are the body's way of signaling the need for immediate glucose intake to raise blood sugar levels.
Choice C rationale:
Increased urination. Increased urination is not a typical symptom of hypoglycemia. In fact, frequent urination may be associated with hyperglycemia (high blood sugar levels) in conditions like diabetes mellitus.
Choice D rationale:
Thirst. Thirst is not a direct symptom of hypoglycemia. Thirst is more commonly associated with hyperglycemia, where high blood sugar levels lead to increased urine output, causing dehydration and subsequent thirst. In hypoglycemia, the focus is on correcting the low blood sugar levels rather than managing thirst.
Correct Answer is B
Explanation
Peer-reviewed journal articles undergo a rigorous review process by experts in the field before being published. This process ensures that the information presented is based on sound research methods, accurate data, and relevant evidence. Journal articles are considered reliable sources of information as they are reviewed by experts in the field, and the research findings can contribute to evidence-based practice.
First-hand experience with wound care products: While personal experience can be valuable, it may not always reflect the most up-to-date or evidence-based practices. Individual experiences can be subjective and may not have been subject to rigorous evaluation or research.
Information from a wound care product vendor: Information from a vendor may be biased and focused on promoting their own products. It is important to critically evaluate the information and consider whether it is supported by evidence and aligns with current best practices.
An entry on a nursing blog addressing wound healing: Blog entries can vary in quality and credibility. Not all blogs are written or reviewed by experts, and the information provided may not always be evidence-based or reliable. It is important to critically assess the source, author's qualifications, and references cited in the blog post.
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