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: A BMI of 18 falls within the underweight range, which is a BMI less than 18.5.
Choice B reason: A healthy weight BMI range is from 18.5 to 24.9, so a BMI of 18 does not fall within this category.
Choice C reason: Obesity is defined as a BMI of 30 or higher, which does not apply to a BMI of 18.
Choice D reason: Overweight is defined as a BMI from 25 to 29.9, so a BMI of 18 is not considered overweight.
Correct Answer is D
Explanation
Choice A reason: Nausea is not a common symptom directly associated with obstructive sleep apnea (OSA).
Choice B reason: Hypotension is not typically a finding in OSA. In fact, OSA can be associated with hypertension due to the effects of recurrent oxygen desaturations and sympathetic nervous system activation.
Choice C reason: Constipation is not a symptom commonly linked to OSA. OSA primarily affects respiratory function
during sleep.
Choice D reason: Morning headaches are a common symptom in individuals with OSA due to disrupted sleep patterns and decreased oxygen levels during apneic episodes.
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