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: Alternating liquids and solids is not a specific intervention for dysphagia management.
Choice B reason: Elevating the head of the bed to 45 degrees or higher during meals can help prevent aspiration in
clients with dysphagia.
Choice C reason: Telling a client with dysphagia to tilt their head back while swallowing can increase the risk of aspiration.
Choice D reason: Turning on the television is not a recommended practice as it can distract the client from focusing
on safe swallowing techniques.
Correct Answer is D
Explanation
Choice A reason: Substernal retractions are not typically associated with pleural effusion; they are more indicative of conditions causing increased work of breathing.
Choice B reason: Crackles are usually heard in conditions like pneumonia or heart failure, but not typically in isolated pleural effusion unless it is associated with other lung conditions.
Choice C reason: Crepitus is generally associated with subcutaneous emphysema when air is present in the
subcutaneous tissue and is not a common finding in pleural effusion.
Choice D reason: Dullness on percussion over the lung fields is a classic finding in pleural effusion due to the presence of fluid in the pleural space.
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