A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
Discontinue the existing IV infusion.
Insert an IV catheter in the opposite extremity.
Apply warm, moist compresses to the site.
Elevate the extremity.
The Correct Answer is A
A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.
B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.
C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.
D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Water heater temperature 54.4°C (130° F):
This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.
B. Electric cords behind furniture:
Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.
C. Bathtub with rails:
Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.
D. Raised toilet seats:
Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.
E. Throw rugs:
Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.
Correct Answer is ["7"]
Explanation
To give the correct dose of amoxicillin 350 mg PO, the nurse needs to calculate how many ml. of the available solution are equivalent to that amount. The available solution has a concentration of 250 mg/5 mL, which means that every 5 ml. contain 250 mg of amoxicillin. To find out how many ml. are needed for 350 mg, the nurse can use a proportion:
250 mg/5 mL = 350 mg/x mL
Cross-multiplying and solving for x, we get:
x = (350 mg x 5 mL) / 250 mg
x = 7 ml.
Therefore, the nurse should administer 7 ml. of the amoxicillin solution.
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