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 A
Explanation
Choice A rationale:
In an interprofessional team meeting for a client, it is essential to include information about changes in the client's condition or any new developments that may impact their care. The statement that "The client has developed difficulty ambulating" is relevant as it indicates a change in the client's mobility status and may require additional interventions or assessments.
Choice B rationale:
The timing of the client's next dressing change (scheduled in 4 hr) is important information but may not be the highest priority to discuss in an interprofessional team meeting. It is more pertinent to focus on the client's current condition and any changes that have occurred.
Choice C rationale:
The client's health insurance status (state-sponsored health insurance) is not typically a central topic of discussion in an interprofessional team meeting unless it directly affects the client's care plan or access to specific treatments.
Choice D rationale:
The frequency of the client's vital sign checks (every 8 hr) is important information for the healthcare team to be aware of, but it may not be the most critical piece of information to include in the interprofessional team meeting. Changes in vital signs or trends would be more relevant to discuss.
Correct Answer is A
Explanation
Choice A rationale:
Reporting a penicillin allergy in the client's history is essential when the client is prescribed cefaclor. Cefaclor is a cephalosporin antibiotic, and individuals with a documented penicillin allergy may have an increased risk of cross-reactivity and allergic reactions to cephalosporin antibiotics. Therefore, it is crucial to report a penicillin allergy to the provider to evaluate the potential risks and consider alternative antibiotics if necessary.
Choice B rationale:
An egg allergy is not directly relevant to the prescription of cefaclor. While allergies to various substances can be important in healthcare, egg allergy is not a contraindication or concern when prescribing cefaclor. Therefore, it does not require specific reporting in this context.
Choice C rationale:
Tendonitis is not directly related to the prescription of cefaclor. Tendonitis is an inflammatory condition affecting tendons and is not typically a contraindication for cefaclor or other cephalosporin antibiotics.
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