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:
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Choice B rationale:
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
Choice C rationale:
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
Choice D rationale:
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.
Correct Answer is D
Explanation
Choice A rationale:
While aspirin does have anti-inflammatory properties, this is not the primary reason it is prescribed post-MI.
Choice B rationale:
Aspirin does have antipyretic properties, but this is not relevant to a history of MI.
Choice C rationale:
Aspirin can act as an analgesic, but this is not the main reason for its prescription post-MI.
Choice D rationale:
Aspirin is an antiplatelet aggregate that helps prevent further clot formation, a key factor in MI treatment.
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