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. Experiencing multiple stressors simultaneously can overwhelm an individual's coping resources and make it more difficult to effectively manage stress. Coping with multiple stressors can lead to feelings of being overwhelmed, heightened anxiety, and decreased ability to cope with each stressor individually.
A. Undergoing a biopsy can be a stressful experience due to uncertainty about the results and fear of the procedure itself. However, the level of difficulty in coping with this stressor can vary among individuals depending on factors such as their coping mechanisms, social support, and previous experiences with medical procedures.
B. Relocating to an assisted-living facility can be a significant life transition, involving changes in living arrangements, loss of independence, and adjustment to a new environment. This stressor can be particularly challenging for individuals who have strong attachments to their current living situation or who are facing health-related issues that necessitate the move.
C. Understanding and researching the stressor can sometimes help individuals cope better by providing knowledge and a sense of control. However, this does not necessarily make coping with the stressor easier, especially if the stressor itself is significant or if the individual lacks adequate support or resources to manage it effectively.
Correct Answer is A
Explanation
A. One of the primary purposes of inserting an NG tube is to decompress the stomach by removing gastric contents. In the case of abdominal distention and severe vomiting, excess gas and fluid accumulation in the stomach can contribute to discomfort and further vomiting. The NG tube provides a way to suction out these contents, relieving pressure and reducing symptoms.
B. NG tubes can also be used to administer medications directly into the stomach. This route is particularly useful when a client is unable to take medications orally due to vomiting or other gastrointestinal issues. Medications can be crushed and dissolved in liquid form before being administered through the NG tube.
C. In some situations, such as when assessing for gastrointestinal bleeding or checking for tube placement, it may be necessary to determine the pH of gastric secretions. Gastric aspirate obtained through the NG tube can be tested for acidity, which can help confirm that the tube is correctly positioned in the stomach and provide information about the client's digestive function.
D. While NG tubes can be used to supply nutrients via tube feedings, this is not typically the primary rationale for their use in the acute situation described (abdominal distention and severe vomiting). However, in cases where a client is unable to tolerate oral intake due to their condition, tube feedings can be administered through the NG tube to provide essential nutrients and maintain nutritional status.
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