A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Remove the IV catheter.

Apply warm or cold compresses.

Stop the infusion.

Apply a sterile dressing.

Elevate the extremity.

Answer and Explanation

The Correct Answer is C,A,E,B,D

Here's the correct order of actions for managing an IV infiltration: C. Stop the infusion. (This is the priority action to prevent further infiltration.) A. Remove the IV catheter. (Once the infusion is stopped, the source of the infiltration needs to be removed.) E. Elevate the extremity. (This helps reduce swelling.) B. Apply warm or cold compresses. (This helps reduce discomfort and swelling. Warm compresses are generally used for non-vesicant solutions, while cold compresses are used for vesicant solutions, or as ordered. The type of fluid infiltrated is important to know.) D. Apply a sterile dressing. (This protects the insertion site and prevents infection.)

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Correct Answer is D

Explanation

Choice A rationale:
The IV site dressing should be changed every 7 days, not every 4 days.
Choice B rationale:
The client’s blood glucose should be monitored every 4-6 hours, not every 12 hours.
Choice C rationale:
The client should be weighed daily, not every other day.
Choice D rationale:
The IV tubing for TPN should be changed every 24 hours to prevent infection.

A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg. B. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg. C. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg. D. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg.

Correct Answer is A

Explanation

Choice A rationale:
These values indicate metabolic acidosis, which is common in clients with chronic kidney disease. The kidneys are unable to excrete hydrogen ions and reabsorb bicarbonate, leading to a low pH and low bicarbonate levels.
Choice B rationale:
These values indicate alkalosis, not typically associated with chronic kidney disease. The pH is high, indicating a basic or alkaline state, and the bicarbonate level is normal.
Choice C rationale:
These values indicate metabolic alkalosis, which is not typically seen in clients with chronic kidney disease. The pH and bicarbonate levels are both high.
Choice D rationale:
These values indicate respiratory acidosis, not typically associated with chronic kidney disease. The high PaCO2 level indicates that the lungs are not effectively eliminating CO2, leading to acidosis.

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A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Nursing Test Bank

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A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).