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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Temperature is not the primary assessment needed before administering propranolol. While it is important to monitor vital signs, temperature does not directly impact the administration of propranolol.
B. Respiratory rate is important to monitor, but it is not the primary assessment needed before administering propranolol. Propranolol primarily affects the cardiovascular system.
C. Pain level is not directly related to the administration of propranolol. While pain management is important, it does not influence the decision to administer propranolol.
D. Heart rate is the primary assessment needed before administering propranolol. Propranolol can cause bradycardia (slow heart rate), so it is crucial to check the client’s heart rate before administration. If the heart rate is below 60 beats per minute, the medication should be withheld, and the provider should be notified.

A. Aspirin B. Sodium bicarbonate C. Diazepam D. Naloxone

Correct Answer is C

Explanation

A. Aspirin is not typically used in the treatment of acute cocaine toxicity. Aspirin is an antiplatelet agent used primarily for its effects on blood clotting and is not indicated for managing the symptoms of cocaine toxicity, which include severe agitation, seizures, and cardiovascular complications.
B. Sodium bicarbonate is used in the treatment of certain types of metabolic acidosis and specific drug overdoses, such as tricyclic antidepressants. However, it is not the first-line treatment for acute cocaine toxicity. The primary concerns in cocaine toxicity are neurological and cardiovascular symptoms, which are better managed with other medications.
C. Diazepam is a benzodiazepine that is commonly used to manage the symptoms of acute cocaine toxicity. It helps to control agitation, seizures, and muscle spasms, which are common manifestations of cocaine overdose. Diazepam’s sedative and anticonvulsant properties make it an effective choice in this scenario.
D. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. Since cocaine is a stimulant and not an opioid, naloxone would not be effective in treating cocaine toxicity. The symptoms and treatment protocols for opioid overdose differ significantly from those for stimulant toxicity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer propranolol to a client. Which of the following should the nurse assess prior to administering this medication?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing manifestations of acute cocaine toxicity. Which of the following medication prescriptions should the nurse anticipate administering?

Correct Answer is C

Explanation

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