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 D
Explanation
Choice A reason: The small intestine is not the starting point of the digestive process. It is where most of the digestion and absorption of nutrients occurs after the food has been processed in the stomach.
Choice B reason: The rectum is the final section of the large intestine, where feces are stored before being expelled. It is not involved in the initial stages of digestion.
Choice C reason: The stomach is involved in the early stages of digestion, particularly in the breakdown of proteins, but it is not the starting point. Food enters the stomach after being ingested through the mouth.
Choice D reason: The mouth is the correct starting location for the digestive process. Here, ingestion takes place, and mechanical digestion begins with chewing, while chemical digestion starts with enzymes in the saliva breaking down carbohydrates.
Correct Answer is D
Explanation
Choice A reason: Magnesium-containing antacids typically cause diarrhea rather than constipation due to magnesium's ability to draw water into the intestines.
Choice B reason: Antibiotics can affect gut flora and potentially cause diarrhea. While some antibiotics may lead to constipation, it is not as common as diarrhea.
Choice C reason: Anticholinergics/antispasmodics can cause constipation because they inhibit the muscle movements in the gastrointestinal tract necessary for bowel movements.
Choice D reason: Opioid narcotics are well-known to cause constipation as they reduce gastrointestinal motility, leading to slower transit times and increased water absorption from the stool.
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