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 A
Explanation
Choice A reason: Muscle weakness is a common symptom of hypokalemia, as potassium is crucial for muscle function and nerve signals that stimulate muscle contractions.
Choice B reason: Cerebral edema is not a typical manifestation of hypokalemia. It is more commonly associated with other conditions such as brain injury or disease.
Choice C reason: Hypertension is generally not a direct result of hypokalemia. In fact, low potassium levels can sometimes lead to lower blood pressure.
Choice D reason: Hyperactive bowel sounds are not specifically associated with hypokalemia. Diarrhea can cause fluid loss leading to hypokalemia, but the condition itself does not cause hyperactive bowel sounds.
Correct Answer is A
Explanation
Choice A reason: Fats help in the absorption of fat-soluble vitamins (A, D, E, and K), which is essential for various bodily functions.
Choice B reason: While fats are involved in the makeup of myelin that insulates nerve cells, they do not directly
regulate nerve cell transmission.
Choice C reason: Fats do not convert to sugar; they are broken down into fatty acids and glycerol to provide energy.
Choice D reason: Proteins are primarily responsible for building and repairing tissues, not fats.
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