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 ["C","D","E"]
Explanation
Apply petroleum jelly around and inside the nares:
Petroleum jelly is not recommended for use with oxygen therapy. It can be flammable and may increase the risk of fire when in contact with oxygen.
B. Cleanse the mask or collar with soapy water every other day:
While it's important to keep the oxygen equipment clean, using soapy water might not be suitable for all types of oxygen masks or collars. Specific cleaning instructions provided by the supplier or healthcare provider should be followed to ensure proper hygiene and maintenance of the equipment.
C. Make sure the straps on the mask are secure but not too tight:
Proper fitting of the oxygen mask is crucial for comfort and adequate oxygen delivery. The straps should be secure enough to hold the mask in place but not so tight as to cause discomfort or skin irritation.
D. Post "no smoking" warning signs at home in a prominent location:
Oxygen is highly combustible, and smoking near oxygen can lead to fires or explosions. It's crucial to have clear warning signs in the home to prevent smoking in areas where oxygen is used.
E. Check the tops of his ears regularly for skin breakdown:
Prolonged use of oxygen masks or nasal cannulas can cause skin breakdown, particularly around the ears where the tubing or mask straps may rest. Regular checks for any signs of skin breakdown are essential for early detection and prevention.
Correct Answer is ["0.5"]
Explanation
To administer lorazepam 1 mg PO to an older adult client who has insomnia and who cannot swallow oral tablets, the nurse should use the lorazepam oral solution 2 mg/mL.
The nurse should calculate the dose by using the formula: Dose (mL) = Desired dose (mg) / Available dose (mg/mL).
In this case, the desired dose is 1 mg and the available dose is 2 mg/mL.
Therefore, the dose (mL) = 1 mg / 2 mg/mL = 0.5 mL.
The nurse should plan to administer 0.5 mL of lorazepam oral solution to the client.
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