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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Narcolepsy is a chronic neurological disorder characterized by excessive daytime sleepiness and other symptoms such as cataplexy (sudden loss of muscle tone), sleep paralysis, and hallucinations. While lifestyle modifications and behavioral strategies may help manage symptoms, medications are often necessary to control narcolepsy symptoms effectively. Therefore, if a client with narcolepsy states that they will not need medications, further teaching is indeed needed.
B. Narcoleptic attacks, or sleep attacks, can indeed last seconds to minutes. They are characterized by sudden and uncontrollable episodes of sleepiness or sleep onset, which can occur during daytime activities.
C. Narcoleptic attacks can occur suddenly, even when the individual is alert and engaged in activities. These attacks are unpredictable and can significantly disrupt daily life.
D. Emotional triggers, such as stress, excitement, or anger, can sometimes precipitate or exacerbate narcoleptic symptoms, including sleep attacks and cataplexy. However, not all individuals with narcolepsy experience triggers in the same way, and triggers can vary among individuals. Therefore, this statement may or may not be true for the individual in question.

A. decreased blood glucose B. Increased mental acuity C. Increased urine retention D. increased bronchial dilation E. decreased pupil size

Correct Answer is ["B","C","D"]

Explanation

B. Increased mental acuity, or heightened alertness and cognitive function, is a characteristic response during the alarm stage of GAS. The body's stress response enhances mental focus and perception to help the individual recognize and respond to the stressor effectively.
C. During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the release of adrenaline (epinephrine) and norepinephrine. These hormones stimulate the kidneys to conserve water and sodium, leading to decreased urine output and increased urine retention. Therefore, increased urine retention is an expected physiologic manifestation in the alarm stage.
D. During the alarm stage, the sympathetic nervous system activation leads to bronchodilation, allowing for increased airflow to the lungs. This facilitates improved oxygenation of the blood and enhances the individual's ability to respond to the stressor by increasing oxygen delivery to tissues.
A. During the alarm stage of GAS, the body initiates the fight-or-flight response, which leads to the release of stress hormones such as cortisol and adrenaline. These hormones increase blood glucose levels through processes like glycogenolysis and gluconeogenesis to provide energy for the body to respond to the stressor. Therefore, decreased blood glucose is not an expected manifestation in the alarm stage.
E. Decreased pupil size: During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the dilation of pupils (mydriasis). This allows for improved visual acuity and peripheral vision, enhancing the individual's ability to detect potential threats or stimuli in the environment.

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The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Nursing Test Bank

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Correct Answer is A

Explanation

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