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 C
Explanation
C. Encourage the client to discuss his feelings about his health status: This option directly targets the affective domain by facilitating the expression and exploration of the client's emotions, attitudes, and beliefs related to their health status. Discussing feelings can help the client process emotions such as fear, anxiety, or frustration, and can promote emotional coping, self-awareness, and acceptance, all of which are important aspects of affective learning.
A. This option primarily involves the psychomotor domain, as it focuses on the client's ability to perform a physical skill (self-measurement of blood pressure). While this activity may indirectly influence the affective domain by building the client's confidence and sense of empowerment in managing their health, its primary focus is on the acquisition of motor skills.
B. This option engages the cognitive domain by encouraging the client to identify and express their informational needs about their diagnosis. While this approach can help address cognitive aspects of learning, such as knowledge acquisition and understanding, it may not directly target the affective domain unless the client's emotional responses and concerns are explicitly addressed.
D. Providing educational materials on exercise and nutrition guidelines can contribute to cognitive learning by imparting information about health behaviors but it may not directly address the affective domain unless the content specifically addresses emotional or motivational aspects of behavior change. However, if the brochures include content that inspires or motivates the client to adopt healthy lifestyle changes by appealing to their values, beliefs, or emotions, then it could indirectly influence the affective domain.
Correct Answer is D
Explanation
D. While considering the opinions of the deceased when making decisions may reflect a continued emotional connection to the deceased partner, it does not necessarily indicate unresolved grief. Many individuals maintain a sense of connection to deceased loved ones and may consider their perspectives or values when making decisions, even after a significant amount of time has passed since the loss. This behavior can be a way of honoring the memory of the deceased and integrating their influence into decision-making processes.
A. Attending grief support group meetings indicates that the client is actively seeking support and processing their grief in a supportive environment. This behavior is consistent with healthy grieving and can contribute to the process of grief resolution by providing opportunities for validation, sharing experiences, and receiving support from others who have experienced similar losses.
B. Being future-oriented and able to discuss the details of everyday life suggests that the client is able to focus on present and future aspects of life, rather than being consumed by grief. This can be a positive sign of adaptation and adjustment to life without the deceased partner. It indicates that the client is able to engage in activities of daily living and plan for the future, which are important aspects of grief resolution.
C. Grief is a complex and individual process that often involves periods of intense emotions, including waves of grief triggered by reminders of the deceased loved one. Experiencing occasional waves of grief triggered by pictures or events is a common experience in the grieving process and does not necessarily indicate unresolved grief. Instead, it reflects the ongoing nature of grief and the client's emotional connection to the deceased.
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