The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?
Stop the infusion immediately
Document the findings in a nurse's note
Flush the catheter with 3ml normal saline
Remove the catheter and apply pressure to the site
The Correct Answer is A
A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This is the most appropriate technique for evaluating the success of teaching a client a psychomotor skill. A return demonstration involves the client independently performing the skill they have been taught while the nurse observes. This allows the nurse to assess the client's ability to execute the skill correctly, including aspects such as technique, coordination, and safety precautions. Additionally, the nurse can provide immediate feedback and correction if necessary, enhancing the client's learning experience.
A. While answering oral questions can assess the client's understanding of theoretical or conceptual knowledge, it may not effectively evaluate their ability to perform a psychomotor skill. Psychomotor skills involve physical actions and coordination, which cannot be adequately assessed through verbal responses alone.
B. Participating in a discussion group can facilitate sharing of experiences and perspectives among clients, but it may not be the most effective method for evaluating the client's ability to perform a psychomotor skill. Discussion groups are more suitable for exploring attitudes, beliefs, and understanding of concepts rather than assessing physical skills.
C. Written tests typically assess cognitive understanding and retention of information rather than the ability to perform psychomotor skills. While written tests can evaluate knowledge about the steps involved in a skill, they do not directly assess the client's ability to execute the skill itself.
Correct Answer is D
Explanation
D. In metabolic acidosis, the pH would be low (acidemic) and the HCO3 level would be below the normal range. In the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, indicating metabolic acidosis.
A. In respiratory alkalosis, the pH would be elevated (alkalotic) and the PaCO2 would be below the normal range (hypocapnia). However, in the provided ABG results, the pH is low (acidemia) rather than high, ruling out respiratory alkalosis.
B. In respiratory acidosis, the pH would be low (acidemic) and the PaCO2 would be above the normal range (hypercapnia). However, in the provided ABG results, the PaCO2 is within the normal range, ruling out respiratory acidosis.
C. In metabolic alkalosis, the pH would be elevated (alkalotic) and the HCO3 level would be above the normal range. However, in the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, ruling out metabolic alkalosis.
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