Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Apply heat to the infiltrated site.

Document a delay in the administration of the antibiotic.

Start a new IV at a different site to administer the antibiotic.

Remove the infiltrated IV catheter.

Answer and Explanation

The Correct Answer is D

A. Applying heat may be indicated later, but the first action should be to address the infiltration.

B. Documenting the delay is important but not the immediate priority.

C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.

D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.

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Correct Answer is D

Explanation

A. Agreeing with the delusions can reinforce the false beliefs and is not an effective therapeutic approach.

B. Disagreeing and setting limits may escalate the client's anxiety or agitation and does not address the delusion in a therapeutic manner.

C. While informing the provider is important, the immediate action should focus on therapeutic communication with the client.

D. Presenting a personal perception of reality in a non-confrontational manner helps the client to gently challenge their delusion and encourages a more grounded conversation.

A. Initiate bilateral intermittent sequential pneumatic compression devices. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. C. Maintain elevated positioning of the dependent joints on affected side. D. Obtain a focused history to determine recent bleeding and use of anticoagulants.

Correct Answer is B

Explanation

A. Initiating sequential pneumatic compression devices is not immediately relevant to managing acute stroke symptoms.

B. Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment helps reduce intracranial pressure and facilitates venous drainage, which is crucial in managing potential stroke patients.

C. Elevating the dependent joints on the affected side is not immediately necessary and does not address the acute neurological symptoms.

D. While obtaining a focused history is important, it should follow after initial stabilization measures such as positioning and securing immediate diagnostic tests.

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Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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