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 A
Explanation
A. Isotonic solutions have a similar osmolarity to that of blood plasma, meaning they exert the same osmotic pressure as blood. This equilibrium prevents the movement of water across cell membranes, thereby maintaining cell volume and preventing cellular dehydration or swelling. Examples of isotonic solutions commonly used for intravenous fluid replacement include 0.9% saline (normal saline) and lactated Ringer's solution.
B. Hypotonic solutions have a lower osmolarity than blood plasma, meaning they exert less osmotic pressure than blood. When administered, hypotonic solutions cause water to move into cells, leading to cellular swelling. While hypotonic solutions can help hydrate cells and replenish intracellular fluid, they are not typically used for rapid volume replacement because they can exacerbate extracellular fluid deficits and cause complications such as cerebral edema or cardiovascular collapse.
C. Hypertonic solutions have a higher osmolarity than blood plasma, meaning they exert greater osmotic pressure than blood. When administered, hypertonic solutions cause water to move out of cells, leading to cellular shrinkage. Hypertonic solutions are often used to expand intravascular volume in cases of severe hypovolemia or shock, as they rapidly increase blood osmolarity and draw fluid from the interstitial space into the bloodstream. Examples of hypertonic solutions include 3% saline and 5% dextrose in 0.9% saline.
D. Hyperosmotic solutions have an elevated osmolarity compared to blood plasma, indicating a higher concentration of solutes. These solutions exert osmotic pressure that draws water out of cells, leading to cellular dehydration. While hyperosmotic solutions are not commonly used for rapid volume replacement due to their pot
Correct Answer is B
Explanation
B. Utilizing an interpreter allows for direct verbal communication between the nurse and the client in their primary language. This ensures accurate transmission of information and facilitates a better understanding of complex concepts. An interpreter can help bridge the language gap and facilitate effective communication during the teaching process.
A. Demonstrations can be effective for teaching clients, regardless of language barriers, as they rely on visual cues and hands-on learning. By demonstrating a procedure or technique and then asking the client to perform a return demonstration, the nurse can assess the client's understanding and competency. This method can be particularly useful when language barriers are present because it relies less on verbal communication.
C. Visual teaching aids, such as diagrams, pictures, charts, and videos, can be powerful tools for conveying information to clients with different primary languages. Visual aids are universal and can help overcome language barriers by presenting information in a way that is easily understood regardless of language proficiency. Using visual aids can enhance comprehension and retention of key concepts.
D. Providing written materials in the client's primary language can be helpful for reinforcing verbal instructions and providing reference materials for the client to review independently. Written materials allow clients to review information at their own pace and refer back to it as needed. However, it's important to ensure that the written materials are accurately translated and culturally appropriate for the client.
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