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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client will use the deltoid muscle as an injection site is incorrect because insulin glargine is typically administered subcutaneously in areas such as the abdomen, thigh, or upper arm, not specifically the deltoid muscle.
B. The client will administer insulin glargine before each meal is incorrect because insulin glargine is a long-acting insulin that is usually administered once daily, not before each meal.
C. The client will take an additional dose of insulin glargine prior to exercise is incorrect because insulin glargine is not typically adjusted based on exercise. Instead, short-acting insulin or dietary adjustments are used to manage blood glucose levels during physical activity.
D. The client will wear his reading glasses when drawing up a dose of insulin glargine is an appropriate outcome. Ensuring that the client can accurately measure and administer the correct dose of insulin is crucial for effective diabetes management and preventing dosing errors.
Correct Answer is D
Explanation
A. Increased appetite can be a positive sign but is not a direct indicator of spironolactone’s effectiveness in treating cirrhosis-related complications.
B. Decreased jaundice is a positive sign but is not the primary indicator of spironolactone’s effectiveness. Jaundice is more directly related to liver function.
C. Increased energy can indicate overall improvement but is not specific to the effects of spironolactone.
D. Decreased ascites is a direct indicator that spironolactone is effective. Spironolactone is a diuretic used to reduce fluid accumulation in the abdomen (ascites) associated with liver cirrhosis. A reduction in ascites indicates that the medication is working as intended.
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