The nurse is working on a neurosurgery unit. The patient calls the desk to complain that his arm is really burning and feels hot. The patient is receiving IV phenytoin for his grand mal seizures. What is the nurse's best action?
Call the health carer provider immediately to change the medication to oral.
Continue the infusion and reassure the patient.
Flush the line with 10 mL of normal saline and continue the infusion.
Discontinue the IV and restart the IV infusion in a different site
The Correct Answer is D
A. Call the health care provider immediately to change the medication to oral.
Changing the medication to oral may not address the immediate issue of the burning sensation and feeling of heat at the IV site. This option focuses on changing the route of administration rather than addressing the current discomfort.
B. Continue the infusion and reassure the patient.
Continuing the infusion without addressing the patient's discomfort could lead to potential complications, and it is important to prioritize patient comfort and safety. Reassurance alone may not be sufficient if there is an issue with the IV site.
C. Flush the line with 10 mL of normal saline and continue the infusion.
While flushing the line with normal saline is a good practice to ensure patency, it may not resolve the issue if there is ongoing irritation or infiltration at the site. Continuing the infusion without addressing the patient's complaint might lead to further discomfort.
D. Discontinue the IV and restart the IV infusion in a different site.
This is the best action. Discontinuing the IV allows the nurse to assess the current site for signs of infiltration or irritation. Restarting the IV in a different site addresses the immediate issue, ensuring that the medication is delivered safely and effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Decreasing physical activity: This is not a helpful intervention for preventing constipation. Physical activity, such as regular exercise, is beneficial for promoting bowel regularity.
B. Decreasing fluid intake: This is not a helpful intervention for preventing constipation. An adequate fluid intake is crucial for maintaining bowel regularity.
C. Nutritional diet high in fiber: This is a correct choice. Consuming a diet rich in fiber helps add bulk to the stool and promotes regular bowel movements, preventing constipation.
D. Increasing fluid intake: This is a correct choice. Staying well-hydrated is important for maintaining bowel regularity. Fluids help soften the stool and aid in its passage.
E. Increasing daily activity: This is a correct choice. Regular physical activity helps stimulate bowel movements and can contribute to preventing constipation.
Correct Answer is ["B","C","D","E"]
Explanation
A. Dietary restriction while taking hydrocodone
There are no specific dietary restrictions associated with hydrocodone use. This option is not relevant to hydrocodone therapy.
B. Instructions not to exceed recommended dosage
It is crucial to emphasize to the patient not to exceed the recommended dosage of hydrocodone. Exceeding the prescribed dose can lead to adverse effects, including respiratory depression.
C. Instructions not to use alcohol or CNS depressants while taking hydrocodone
Hydrocodone is a central nervous system (CNS) depressant. Combining it with alcohol or other CNS depressants can increase the risk of respiratory depression and sedation. Patients should be advised to avoid alcohol and other drugs that depress the CNS.
D. Instructions on how to prevent constipation
Opioid medications, including hydrocodone, can cause constipation. Patients should receive instructions on how to prevent constipation, such as increasing fluid and fiber intake and incorporating regular physical activity.
E. Side effects to report
Patients should be educated about potential side effects of hydrocodone and instructed to report any unusual or severe side effects to their healthcare provider promptly. This may include symptoms such as respiratory distress, severe drowsiness, or allergic reactions.
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