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.
The Correct Answer is C,A,D,E,B
The correct answer is choice C, A, D, E, B. Here are the rationales for each choice: Choice C rationale: Stop the infusion. The first step when an infiltration is identified is to stop the infusion. This is to prevent further infiltration of the IV fluid into the surrounding tissue. Choice A rationale: Remove the IV catheter. After stopping the infusion, the next step is to remove the IV catheter. This is to prevent any more fluid from being infused into the infiltrated area. Choice D rationale: Apply a sterile dressing. Once the IV catheter is removed, a sterile dressing should be applied to the site. This helps to prevent infection. Choice E rationale: Elevate the extremity. The affected extremity should be elevated. This helps to reduce swelling and discomfort. Choice B rationale: Apply warm or cold compresses. Finally, warm or cold compresses should be applied as per the facility’s policy. This can help to alleviate pain and reduce swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
Correct Answer is A
Explanation
Choice A rationale:
Varicose veins with ulcerations and lower extremity edema indicate poor blood flow, hence impaired tissue perfusion is the priority.
Choice B rationale:
While activity tolerance might be affected, it’s not the immediate concern.
Choice C rationale:
Impaired skin integrity is a concern due to ulcerations, but it’s secondary to impaired perfusion.
Choice D rationale:
Body image might be affected, but it’s not a physiological priority.
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