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
Explanation
A. "I need to increase my fluid intake." - This is a correct statement. Sucralfate should be taken with plenty of water to ensure proper absorption and effectiveness.
B. "I need to report pain or vomiting of blood." - This is also a correct statement. Severe abdominal pain or vomiting of blood may indicate a serious issue and should be reported to the healthcare provider.
C. "I need to take Carafate 30 minutes after meals." - This is an incorrect statement. Sucralfate is typically taken on an empty stomach, about 1 hour before meals and at bedtime.
D. "I need to take Maalox 30 minutes before or after Carafate." - This statement is correct. Antacids like Maalox can interfere with the absorption of sucralfate. It's generally recommended to space them apart, taking sucralfate at least 30 minutes before or after antacids.
Correct Answer is D
Explanation
A. High-sodium foods: Sodium intake is not specifically contraindicated with methylphenidate (Ritalin). However, maintaining a balanced and healthy diet is generally recommended for overall well-being.
B. High-sugar foods and drinks: While there is no strict contraindication with methylphenidate and sugar, a diet high in sugar may contribute to hyperactivity and may not be conducive to managing symptoms of ADHD. It's advisable to promote a balanced diet with reduced sugar intake.
C. High-fat foods: There is no direct contraindication between methylphenidate and high-fat foods. However, maintaining a balanced diet with a moderate intake of fats is generally recommended for overall health.
D. Caffeinated foods and drinks: This is the correct answer. Methylphenidate is a stimulant, and combining it with additional sources of caffeine can lead to an increase in stimulant effects, potentially causing adverse reactions.
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