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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly, white borders. It is the most common type of skin cancer.
Choice B rationale:
Actinic keratosis is a precancerous skin condition that can lead to squamous cell carcinoma if left untreated. It typically presents as dry, scaly patches or spots.
Choice C rationale:
Squamous cell carcinoma often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale:
Malignant melanoma is a more serious type of skin cancer that can develop anywhere on the body. It often appears as a new, irregular, or changing mole.
Correct Answer is D
Explanation
Choice A rationale:
Fluoxymesterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice B rationale:
Danazol is a synthetic steroid that is used to treat endometriosis, but it’s not used for BPH.
Choice C rationale:
Methyltestosterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice D rationale:
Finasteride is a medication that is used to treat BPH. It works by decreasing the size of the prostate gland.
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