The nurse is caring for a client receiving an intravenous medication that is a vesicant. The IV flow has stopped and there is pain, burning and swelling at the IV site. What action should the nurse take first?
Elevate the extremity on a pillow
Immediately remove the catheter
Keep the catheter in place
Place a cool compress on the area
The Correct Answer is B
B. When a client experiences symptoms of extravasation, such as pain, burning, and swelling, especially with a vesicant medication, the priority is to stop the infusion and remove the catheter immediately to prevent further tissue damage. Removing the catheter promptly helps minimize the amount of medication that may have leaked into the surrounding tissues.
A. Elevating the extremity on a pillow may help reduce swelling and discomfort in some cases, but it is not the first action the nurse should take when a vesicant medication has caused pain, burning, and swelling at the IV site.
C. Keeping the catheter in place is not advisable when extravasation has occurred, especially with a vesicant medication. Continuing the infusion could lead to further tissue damage and exacerbate the client's symptoms. Removing the catheter is necessary to prevent additional medication from entering the surrounding tissues.
D. While applying a cool compress may provide temporary relief from discomfort, it is not the first action the nurse should take when managing extravasation caused by a vesicant medication. The priority is to stop the infusion, remove the catheter, and assess the extent of tissue damage. Cool compresses may be used after the catheter removal to help reduce swelling and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
C. Sleep plays a crucial role in stress management and resilience. Adequate sleep helps regulate stress hormones such as cortisol, promotes emotional regulation, and enhances coping mechanisms. Chronic sleep deprivation can lead to increased stress levels and reduced ability to cope with stressors.
D. Sleep is essential for the restoration and repair of both the mind and body. During sleep, the body undergoes processes such as tissue repair, muscle growth, and memory consolidation. Sleep also allows the brain to clear toxins and waste products accumulated during wakefulness, promoting cognitive function and overall well-being.
E. One of the functions of sleep is to conserve energy. During sleep, metabolic rate and energy expenditure decrease, allowing the body to conserve resources for essential physiological processes. Sleep helps replenish energy stores, repair cellular damage, and prepare the body for the next day's activities.
A. Sleep has been shown to have analgesic effects and can improve pain tolerance. Adequate sleep helps reduce the perception of pain and promotes the release of endogenous pain-relieving substances in the body.
B. During sleep, blood pressure typically decreases as part of the normal sleep-wake cycle. However, certain sleep disorders, such as sleep apnea, may lead to fluctuations in blood pressure during sleep. Overall, quality sleep is important for maintaining cardiovascular health and regulating blood pressure.
Correct Answer is ["A","B"]
Explanation
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
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