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 B

Explanation

The correct answer is choice B. Inject 20 units of air into the NPH insulin vial.

Choice A rationale:

Replacing the needle for withdrawal with a safety needle is an important step to ensure safety and prevent needle-stick injuries. However, this action is not the first step when mixing two types of insulin. The initial steps involve preparing the insulin vials by injecting air into them.

Choice B rationale:

Injecting 20 units of air into the NPH insulin vial is the correct first step. This is because NPH insulin is a suspension and needs to be mixed properly. Injecting air into the vial helps to equalize the pressure, making it easier to withdraw the correct amount of insulin later. This step is crucial to ensure accurate dosing and proper mixing of the insulin.

Choice C rationale:

Injecting 10 units of air into the regular insulin vial is also necessary, but it is not the first step. The correct sequence is to first inject air into the NPH insulin vial, then into the regular insulin vial. This order helps prevent contamination of the regular insulin with NPH insulin.

Choice D rationale:

Withdrawing 10 units of insulin from the regular insulin vial is an important step, but it should be done after injecting air into both vials. The correct sequence ensures that the insulin is mixed properly and that the doses are accurate.

By following these steps in the correct order, the nurse ensures that the insulin is mixed safely and effectively, minimizing the risk of errors and ensuring proper glycemic control for the patient.

A. Sublingual. B. Suspended-release. C. Transdermal patch. D. Topical ointment.

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.

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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 preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?

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.).