A nurse is caring for a client who is receiving a continuous intravenous infusion containing a vesicant that has become infiltrated. Which of the following actions should the nurse take first in treating this condition?

Start another IV line in another extremity.

Apply a warm, moist compress.

Disconnect IV tubing and aspirate medication from the IV catheter.

Stop the infusion.

Answer and Explanation

The Correct Answer is D

A. Start another IV line in another extremity: Establishing a new IV line is necessary to continue therapy, but it is not the first action. Immediate steps must focus on preventing further tissue damage from the infiltrated vesicant.

B. Apply a warm, moist compress: Warm or cold compresses may be applied depending on the type of vesicant and institutional protocol, but this is a secondary intervention after stopping the infusion and protecting the tissue.

C. Disconnect IV tubing and aspirate medication from the IV catheter: Aspirating the remaining medication may help reduce tissue exposure, but it is performed after the infusion is stopped to prevent further infiltration.

D. Stop the infusion: Stopping the infusion immediately is the first and most critical action to prevent further tissue damage. Halting the delivery of the vesicant stops the source of injury and allows subsequent interventions to minimize local tissue necrosis.

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Correct Answer is B

Explanation

A. "I can change my cat's litter box every day.": Clients with leukemia are immunocompromised and at increased risk for infections such as toxoplasmosis from cat feces. They should avoid changing litter boxes or use protective measures like gloves and masks, so this statement indicates a misunderstanding of infection prevention.

B. "I will avoid blowing my nose when I feel congested.": Avoiding forceful nose blowing helps prevent mucosal trauma and bleeding, which is important for clients with leukemia who may have thrombocytopenia or fragile mucous membranes. This statement demonstrates an understanding of precautions to reduce injury and infection risk.

C. "I can continue gardening in my yard.": Gardening exposes the client to soilborne pathogens and bacteria, increasing the risk of infection. Clients with leukemia should avoid activities that involve soil contact unless using strict protective measures, so this statement indicates a lack of understanding.

D. "I will clean my toothbrush with an alcohol-based mouthwash.": Cleaning a toothbrush with mouthwash is not sufficient to prevent microbial contamination. Clients with leukemia should use a soft-bristled toothbrush and replace it regularly to minimize infection risk. This statement reflects incomplete understanding of oral care precautions.

A. Delegate scheduled checks to assistive personnel. B. Ensure all the side rails are up when the client is in bed. C. Collaborate with a provider to request PRN standard prescriptions for sedatives. D. Keep televisions on around the unit for distraction.

Correct Answer is A

Explanation

A. Delegate scheduled checks to assistive personnel: Regular, scheduled checks help monitor clients with moderate dementia for signs of restlessness, wandering, or unsafe behaviors that could lead to falls. Delegating this task ensures consistent supervision and enhances safety.

B. Ensure all the side rails are up when the client is in bed: Raising all side rails can actually increase the risk of injury, as clients with dementia may attempt to climb over them, leading to falls or entrapment. Side rails should be used judiciously and according to safety guidelines.

C. Collaborate with a provider to request PRN standard prescriptions for sedatives: Routine use of sedatives can increase confusion, dizziness, and fall risk in clients with dementia. Nonpharmacologic fall prevention strategies are preferred whenever possible.

D. Keep televisions on around the unit for distraction: Continuous background noise or television can be overstimulating and may increase agitation in clients with dementia, potentially increasing the risk of falls rather than preventing them.

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A nurse is caring for a client who is receiving a continuous intravenous infusion containing a vesicant that has become infiltrated. Which of the following actions should the nurse take first in treating this condition?

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Naxlex Comprehensive Predictor Exams

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