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,D,E,B

Here’s the correct order of actions a nurse should take when infiltration is identified at an IV site: C. Stop the infusion A. Remove the IV catheter D. Apply a sterile dressing E. Elevate the extremity B. Apply warm or cold compresses ? Rationale: Stopping the infusion prevents further infiltration. Removing the catheter eliminates the source of fluid leakage. Applying a sterile dressing protects the site from infection. Elevation helps reduce swelling. Compresses (warm for older infiltrations, cold for recent ones) promote absorption and comfort.

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Correct Answer is A

Explanation

Choice A rationale:
Providing warm slipper-socks can help increase the client’s comfort by keeping their feet warm.
Choice B rationale:
Increasing the client’s oral fluid intake would not directly affect the temperature of their feet.
Choice C rationale:
Rubbing the client’s feet briskly for several minutes could potentially harm the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Choice D rationale:
Placing a moist heating pad under the client’s feet could potentially burn the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.

A. Dextrose 10% in water. B. 3% sodium chloride. C. 0.9% sodium chloride. D. Lactated Ringer's. .

Correct Answer is A

Explanation

Choice A rationale:
Dextrose 10% in water can be used as a temporary replacement for TPN to prevent hypoglycemia until the TPN solution is available.
Choice B rationale:
3% sodium chloride is a hypertonic solution and is not typically used as a replacement for TPN.
Choice C rationale:
0.9% sodium chloride, or normal saline, does not provide the necessary nutrients that are included in TPN.
Choice D rationale:
Lactated Ringer’s is used for fluid resuscitation and does not provide the necessary nutrients that are included in TPN.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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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.).