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 D
Explanation
D. Consuming alcoholic beverages, especially close to bedtime, can disrupt sleep patterns and exacerbate insomnia. While alcohol may initially have a sedative effect and induce drowsiness, it can lead to fragmented and poor-quality sleep later in the night, resulting in worsened insomnia symptoms. Therefore, this statement indicates a need for further education by the nurse regarding the negative impact of alcohol consumption on sleep and the importance of avoiding alcohol before bedtime to improve sleep quality.
A. Keeping the bedroom cool (around 65 degrees Fahrenheit) is generally recommended for promoting sleep because a cooler temperature can help facilitate the body's natural temperature drop, which occurs during sleep onset.
B. Engaging in regular physical activity, such as taking a long walk during the day, can be beneficial for promoting better sleep. Physical activity during the day can help regulate the sleep-wake cycle, reduce stress, and improve overall sleep quality. Therefore, this statement reflects a positive sleep hygiene practice and does not indicate a need for further education.
C. This statement suggests an understanding of the importance of associating the bed with sleep and avoiding activities that may interfere with sleep, such as paying bills or working in bed. Maintaining the bed as a place primarily for sleep and intimacy can help condition the mind and body to associate the bed with relaxation and sleep.
Correct Answer is A
Explanation
A. It's essential for nurses caring for dying patients to be comfortable with their own feelings about death and dying. Being comfortable with mortality allows nurses to provide compassionate care, support families, and engage in end-of-life discussions with patients. Nurses who are comfortable with their own feelings about death are better equipped to provide holistic care and support to dying patients and their families.
B. Hospice services focus on providing comfort and support to terminally ill patients and their families during the end-of-life journey. While hospice services are often beneficial and recommended for patients approaching the end of life, preferences vary among individuals and families. Some patients may choose to receive hospice care, while others may prefer to remain at home with palliative care support or receive care in a hospital or long-term care facility.
C. While some patients may experience pain as death nears, it is not necessarily true that "most" deaths are accompanied by significant pain. With advances in palliative care and pain management, many patients can experience a comfortable and peaceful death with effective symptom management.
D. Most people are not frightened to die if they have adequate information about what is happening: While adequate information and preparation can alleviate some fears about death, attitudes and responses to death vary widely among individuals. Some people may find comfort and acceptance in understanding the dying process and what to expect, while others may still experience fear, anxiety, or uncertainty regardless of the information provided.
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