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. Return the remaining medication to the facility’s pharmacy. This action is not appropriate because it is not standard practice to return partially used medications to the pharmacy.
B. Dispose of the remaining medication while another nurse observes. This action is correct. Proper disposal of controlled substances like hydromorphone requires witnessing by another nurse to ensure accountability and prevent misuse.
C. Store the remaining half of the pill in the automated medication dispensing system. This action is not appropriate because storing a half tablet in the dispensing system can lead to contamination and dosing errors.
D. Place the remaining half of the pill in the unit-dose package. This action is not appropriate because it does not ensure proper disposal and could lead to medication errors or misuse.
Correct Answer is B
Explanation
A. PTT (partial thromboplastin time) is used to monitor heparin therapy, not warfarin. It measures the intrinsic pathway of coagulation.
B. PT (prothrombin time) is the correct test to review before administering warfarin. PT measures the extrinsic pathway of coagulation and is used to calculate the INR (International Normalized Ratio), which helps monitor and adjust warfarin dosage to ensure therapeutic levels and prevent complications.
C. Total iron-binding capacity is a measure of iron status and is not relevant to warfarin therapy.
D. WBC (white blood cell count) is important for assessing infection or immune status but is not directly related to monitoring warfarin therapy.
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