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 B
Explanation
Choice A reason: An upper GI series is a series of X-rays used to examine the esophagus, stomach, and small intestine, not the rectum or colon.
Choice B reason: A colonoscopy is the most appropriate test for screening for rectal cancer as it allows for the
examination of the entire colon and rectum and can also facilitate the removal of polyps.
Choice C reason: ERCP is primarily used to diagnose and treat conditions in the liver, gallbladder, bile ducts, and pancreas, not the rectum.
Choice D reason: An upper GI endoscopy, or esophagogastroduodenoscopy (EGD), is used to examine the lining of the upper part of the gastrointestinal tract, which includes the esophagus, stomach, and duodenum, not the rectum.
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Correct Answer is B
Explanation
Choice A reason: Metabolic alkalosis is not commonly associated with COPD. It occurs when there is an accumulation
of bicarbonate or a loss of hydrogen ions.
Choice B reason: Respiratory acidosis is a common acid-base imbalance in clients with COPD. It occurs due to the retention of CO2 as a result of reduced respiratory function.
Choice C reason: Metabolic acidosis is characterized by a decrease in serum bicarbonate and is not typically a direct
result of COPD.
Choice D reason: Respiratory alkalosis occurs when there is a decrease in CO2 levels, which is the opposite of what is expected in COPD.
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