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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) pH 7.36 (7.35 to 7.45), PaCO2 38 mm Hg (35 to 45 mmHg), HCO3 25 mEq/L (22 to 26 mEq/L): This is a normal set of arterial blood gas (ABG) values, with a pH within normal range, a normal PaCO2, and a normal HCO3. It does not suggest metabolic alkalosis.

B) pH 7.48 (7.35 to 7.45), PaCO2 32 mm Hg (35 to 45 mm Hg), HCO3 24 mEq/L (22 to 26 mEq/L): Although the pH is elevated, indicating alkalosis, the PaCO2 is slightly low, and the bicarbonate (HCO3) is within the normal range. This set of values does not indicate metabolic alkalosis, but could indicate respiratory alkalosis or compensated alkalosis.

C) pH 7.46 (7.35 to 7.45), PaCO2 36 mm Hg (35 to 45 mm Hg), HCO3 29 mEq/L (22 to 26 mEq/L): This is consistent with metabolic alkalosis. The elevated pH (alkalosis) combined with an increased bicarbonate level (HCO3 > 26 mEq/L) and a normal PaCO2 suggests metabolic alkalosis, as the kidneys retain bicarbonate to compensate for the condition.

D) pH 7.26 (7.35 to 7.45), PaCO2 35 mm Hg (35 to 45 mm Hg), HCO3 18 mEq/L (22 to 26 mEq/L): This set of values indicates acidosis, not alkalosis. The pH is low, indicating acidosis, and the bicarbonate (HCO3) is also low, which suggests metabolic acidosis. The PaCO2 is normal, which further supports a metabolic origin of the acidosis.

A. Temperature B. Blood pressure C. Pain D. Urine output E. Heart rate F. Respiratory status G. Sodium level H. Mental confusion I. Serum amylase level J. Cold, clammy skin

Correct Answer is ["A","B","E","F","H","J"]

Explanation

A. Temperature: The client’s temperature increased from 37.2°C (99°F) to 38.9°C (102°F), indicating a possible infection or systemic inflammatory response. Fever in acute pancreatitis can suggest worsening inflammation, infection, or sepsis and should be reported immediately.
B. Blood pressure: The client's blood pressure dropped from 126/78 mmHg to 92/48 mmHg, indicating hypotension, which could be due to fluid shifts, systemic inflammation, or early shock. Immediate intervention is necessary to prevent hemodynamic instability.
C. Pain: While severe pain (rated 10/10) is expected in acute pancreatitis, it is not the most urgent concern requiring immediate reporting compared to hemodynamic instability and respiratory distress.
D. Urine output: The current urine output is not critically low (50-60 mL/hr), but continued monitoring is necessary. However, it is not an immediate life-threatening concern requiring urgent reporting.
E. Heart rate: The client’s heart rate increased from 90/min to 132/min, which is a significant tachycardia. This suggests compensatory shock, fluid loss, or worsening systemic inflammation and requires immediate provider notification.
F. Respiratory status: The respiratory rate increased from 18/min to 32/min, and oxygen saturation dropped to 88% on 3 L/min O₂. This suggests respiratory compromise, possibly due to worsening systemic inflammation, pleural effusion, or acute respiratory distress syndrome (ARDS).
G. Sodium level: The sodium level remains within the normal range (142 mEq/L; normal: 136-145 mEq/L), so it does not require immediate reporting.
H. Mental confusion: The client, who was alert on Day 1, is now disoriented. This change in mental status can indicate worsening systemic inflammation, hypoxia, or impending shock, requiring urgent intervention.
I. Serum amylase level: While elevated (498 units/L), this is expected in pancreatitis and does not require immediate notification unless there is a sudden drastic change.
J. Cold, clammy skin: This is a sign of poor perfusion and possible shock. It indicates worsening hemodynamic instability and requires immediate intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results for a client who has metabolic alkalosis. Which of the following blood gas values should the nurse expect?

Correct Answer is C

Explanation

A nurse is assisting in the care of a newly admitted client. Which of the following findings should the nurse report immediately to the provider? Select all that apply

Correct Answer is ["A","B","E","F","H","J"]

Explanation

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

A nurse is assisting with the care of client. Drag 1 condition and 1 finding to fill in each blank in the following sentences The client likely suffered from ____ as evidenced by ____ .

A nurse is collecting a health history from the guardian of a 4year old child. Which of the following statements by the guardian is the priority for the nurse to address?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?