A nurse is caring for client who is receiving a continuous IV infusion . The nurse notes the skin around the catheter's insertion site is edematous and cool. Which of the following actions is should the nurse take First?
Document the infiltration
Elevate the arm
Apply a warm compress.
Stop the infusion.
The Correct Answer is D
A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.
B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.
C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.
D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.
B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.
C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.
D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.
E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.
Correct Answer is C
Explanation
A) Dampened clothes are used for dusting the area: Using dampened clothes for dusting can help minimize the spread of dust and particulate matter in the environment. As long as the cloth is clean and properly disinfected, this action is not typically a source of infection. This is generally a safer approach for cleaning and does not pose an immediate infection risk.
B) Waste containers are lined with: While the phrasing is incomplete, if waste containers are lined properly with appropriate liners and are disposed of regularly, they should not serve as a significant source of infection. Waste disposal is important, but a properly lined container reduces the risk of contamination.
C) Soiled linens are placed on the floor: Placing soiled linens on the floor is a significant source of potential infection for immunocompromised clients. Floors can harbor bacteria, viruses, and other pathogens, and placing soiled linens there increases the likelihood of cross-contamination. The linens should be handled in a way that prevents contact with unclean surfaces to avoid spreading infection.
D) Uncapped sharps are put in a puncture-resistant container: A puncture-resistant container is designed to safely contain sharps such as needles, scalpels, or other sharp objects, minimizing the risk of injury. If sharps are uncapped, however, they could present a risk of needle-stick injury or contamination. However, the main risk comes from improper disposal, not the container itself. Proper disposal in an appropriately designed container is essential to minimizing infection risks.
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