A nurse is caring for a client who is receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take?
Aspirate fluid from the IV cannula.
Place the affected extremity below the level of the client's heart.
Slow the IV infusion.
Place a pressure dressing over the IV site.
The Correct Answer is C
Choice A reason: Aspirating fluid from the IV cannula is not recommended as it does not address the issue of infiltration or extravasation.
Choice B reason: Placing the affected extremity below the level of the client's heart could worsen the swelling and is
not recommended.
Choice C reason: Slowing the IV infusion is a correct immediate action to minimize further infiltration and should be done while further assessment and interventions are planned.
Choice D reason: Placing a pressure dressing over the IV site is not recommended as it may exacerbate the infiltration
and increase discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Memory loss is not typically associated with vitamin C deficiency. Memory loss can be related to various conditions, including neurological disorders or vitamin B12 deficiency.
Choice B reason: Brittle hair can be a sign of vitamin C deficiency due to its role in collagen production, which affects the health of hair. However, it is not as specific or common as bleeding gums.
Choice C reason: Bleeding gums are a common symptom of vitamin C deficiency. Vitamin C is essential for the maintenance of healthy connective tissue, which includes the gums. A deficiency can lead to scurvy, which manifests as bleeding gums among other symptoms.
Choice D reason: Constipation is not directly associated with vitamin C deficiency. While a healthy diet rich in vitamin C can aid digestion, constipation can be caused by a variety of factors unrelated to vitamin C intake.
Correct Answer is C
Explanation
Choice A reason: Metabolic Acidosis typically results from conditions that increase acid production or decrease acid excretion, not from vomiting.
Choice B reason: Respiratory Acidosis is caused by hypoventilation leading to an accumulation of carbon dioxide, which is not directly related to vomiting.
Choice C reason: Metabolic Alkalosis can occur due to the loss of stomach acids through prolonged vomiting, leading to an excess of bicarbonate in the body fluids.
Choice D reason: Respiratory Alkalosis is usually caused by hyperventilation, not by vomiting.
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