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 A
Explanation
A. Avoid caffeine-containing beverages before sleep
The highest priority teaching point to help relieve sleeplessness would be to advise the client to avoid caffeine-containing beverages before sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and maintain a restful sleep.
B. Perform strenuous exercise before bedtime
Strenuous exercise close to bedtime can actually stimulate the body and make it more difficult for the individual to relax and fall asleep. It is generally recommended to engage in exercise earlier in the day.
C. Drink lots of fluids before bedtime
Drinking excessive fluids before bedtime may lead to disrupted sleep as it can increase the need to wake up for bathroom trips during the night. It's advisable to limit fluid intake close to bedtime.
D. Eat a heavy meal before bedtime
Consuming a heavy meal before bedtime can cause discomfort and indigestion, potentially disrupting sleep. It is recommended to have a light, easily digestible meal if eating close to bedtime.
Correct Answer is D
Explanation
A. Calm the patient to reduce acid production.
This description is not accurate for sucralfate. Calming the patient to reduce acid production is typically associated with medications like proton pump inhibitors (PPIs) or H2 receptor blockers.
B. Block the H2 receptors.
Blocking H2 receptors is the mechanism of action for H2 receptor blockers, such as ranitidine. It is not the mechanism of action for sucralfate.
C. Neutralize the gastric acids.
Neutralizing gastric acids is the mechanism of action for antacids, such as aluminum hydroxide or calcium carbonate. Sucralfate works differently; it forms a protective coating on the gastric lining rather than directly neutralizing acids.
D. Coat the gastric lining.
This is the correct mechanism of action for sucralfate. It forms a protective coating on the gastric lining, adhering to the ulcer site and providing a barrier against gastric acid.
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