A nurse is monitoring a client’s peripheral IV infusion of a vesicant medication and observes swelling and coolness of the skin at the insertion site. After stopping the infusion, which of the following actions should the nurse take next?
Notify the provider.
Apply a warm, moist compress.
Aspirate fluid remaining in the catheter.
Remove the IV catheter.
The Correct Answer is D
A. Notify the provider. While notifying the provider is important, it is not the immediate next step after stopping the infusion. The priority is to prevent further damage by removing the IV catheter.
B. Apply a warm, moist compress. This action may be appropriate depending on the type of vesicant, but it is not the immediate next step. The priority is to remove the IV catheter to prevent further extravasation.
C. Aspirate fluid remaining in the catheter. This action can help to remove any remaining vesicant from the tissue, but it is not the immediate next step. The priority is to remove the IV catheter.
D. Remove the IV catheter. This is the correct next step after stopping the infusion. Removing the catheter helps to prevent further leakage of the vesicant into the surrounding tissue, minimizing the risk of tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Check the client’s medical record for medication and food interactions is important, but it may not provide comprehensive information about all potential interactions.
B. Consult a drug reference guide for possible interactions is the best action. Drug reference guides provide detailed and up-to-date information about potential food and medication interactions, ensuring safe administration.
C. Ask another nurse if they are aware of potential interactions can be helpful, but it should not be the primary source of information. It is better to rely on authoritative drug reference guides.
D. Have the client take the medication on an empty stomach to avoid interactions is not always appropriate. Some medications need to be taken with food to enhance absorption or reduce gastrointestinal side effects.
Correct Answer is D
Explanation
A. Oral candidiasis is not a common adverse effect of metoclopramide. It is more commonly associated with antibiotic use.
B. Black stools can indicate gastrointestinal bleeding but are not a typical adverse effect of metoclopramide.
C. Dry cough is not associated with metoclopramide. It is more commonly related to respiratory conditions or certain medications like ACE inhibitors.
D. Tardive dyskinesia is a serious adverse effect of metoclopramide, especially with long-term or high-dose use. It involves involuntary, repetitive movements and can be irreversible.
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