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:
Sublingual administration of nitroglycerin provides the most rapid onset. This route allows the medication to be absorbed directly into the bloodstream through the mucous membranes under the tongue, bypassing the digestive system.
Choice B rationale:
Sustained-release nitroglycerin is designed to be released slowly over time. This form of the drug does not provide rapid relief of acute angina symptoms.
Choice C rationale:
Transdermal patches of nitroglycerin provide a slow, continuous dose of medication. This is beneficial for long-term management of angina, but it does not provide rapid relief.
Choice D rationale:
Topical ointments also provide a slow, continuous dose of medication and are not intended for rapid relief of acute symptoms.

A. Determine if the client needs to continue IV therapy. B. Initiate a new IV line in the other extremity. C. Discontinue the existing IV line. D. Apply a hot pack to the irritated site.

Correct Answer is C

Explanation

Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.

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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.).