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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While bananas are well-known for their potassium content, with one medium banana containing about 451 mg of potassium, they are not the highest source among the options given.
Choice B reason: Spinach is also a good source of potassium, with 1 cup of cooked spinach offering about 830 mg. However, it still does not surpass the potassium content of a baked potato.
Choice C reason: Avocados contain potassium, with one-half cup providing 364 mg. Despite their health benefits,
they have less potassium compared to a baked potato.
Choice D reason: Baked potatoes contain the highest amount of potassium among the options listed. One medium baked potato has 929 mg of potassium, making it the best choice for someone at risk for hypokalemia.
Correct Answer is C
Explanation
Choice A reason: The reservoir bag on a nonrebreather mask should not collapse with exhalation. It is designed to maintain a continuous flow of oxygen and reserve a volume of oxygen for the patient to inhale with each breath.
Choice B reason: While high-flow oxygen can dry a patient's mucous membranes, a nonrebreather mask typically has a high oxygen flow rate, and humidification can be used to prevent drying.
Choice C reason: A nonrebreather mask must fit snugly over the patient's face to ensure that the highest concentration of oxygen is delivered and that there is minimal dilution with room air.
Choice D reason: A nonrebreather mask is used to deliver high-flow oxygen, not low-flow. It is designed to provide a high concentration of oxygen, typically around 60% to 90% FiO2.
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