The nurse is administering promethazine via an IV pump and notices that the IV has infiltrated and the patient reports a burning sensation at the injection site.
What should be the nurse’s priority action?
Notify the healthcare provider
Add promethazine to the allergy list
Continue to monitor the site
Stop the IV infusion .
The Correct Answer is D
Choice A rationale
While notifying the healthcare provider is an important step when an IV has infiltrated, it is not the immediate priority action.
Choice B rationale
Adding promethazine to the allergy list would not be appropriate unless the patient had an allergic reaction to the medication.
Choice C rationale
Continuing to monitor the site would not be the immediate priority action. The nurse should first stop the IV infusion to prevent further damage.
Choice D rationale
The nurse’s priority action should be to stop the IV infusion. This prevents further infiltration and potential tissue damage. After stopping the infusion, the nurse can then take further steps such as notifying the healthcare provider and assessing the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Digoxin is a cardiac glycoside used to treat heart failure and atrial fibrillation. While it’s important to monitor digoxin levels in patients receiving gentamicin due to the risk of increased digoxin levels, it’s not the most concerning medication.
Choice B rationale
Furosemide is a loop diuretic that can cause ototoxicity, especially when used with aminoglycosides like gentamicin. Therefore, this is the medication the nurse should be most concerned about.
Choice C rationale
Prednisolone is a corticosteroid medication. While it’s important to monitor for potential interactions, it’s not the most concerning medication in this context.
Choice D rationale
Warfarin is an anticoagulant medication. While it’s important to monitor for potential interactions, it’s not the most concerning medication in this context.
Correct Answer is C
Explanation
Choice A rationale
Infusing the medication slowly over a period of 60-90 minutes is a common practice for many intravenous medications to prevent adverse reactions. However, this is not the first step a nurse should take before administering intravenous acyclovir.
Choice B rationale
While diluting certain medications in a liter of normal saline can be a part of the preparation process, it is not the first step a nurse should take before administering intravenous acyclovir.
Choice C rationale
Checking the intravenous site for any signs of redness, heat, or swelling is the correct first step before administering any intravenous medication. This is to ensure that the IV site is not infected or inflamed, which could lead to complications such as phlebitis or infiltration.
Choice D rationale
Examining the patient for any open herpetic lesions is important when administering acyclovir, as the medication is used to treat herpes infections. However, this is not the first step a nurse should take before administering the medication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.