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 D

Explanation

D. 0.9% sodium chloride (0.9% NaCl): This solution, also known as normal saline, is isotonic and contains the same concentration of sodium as extracellular fluid. It is the most appropriate choice for initial fluid resuscitation in hypovolemia due to severe bleeding because it rapidly expands intravascular volume, replaces sodium losses, and helps restore circulating blood volume.
A. This solution contains dextrose (glucose) and a small amount of sodium chloride. It provides some glucose for energy but has a lower sodium concentration compared to isotonic solutions like normal saline. While it may be used in certain situations, such as to provide maintenance fluids or correct mild dehydration, it is not the first choice for fluid resuscitation in hypovolemia due to severe bleeding because it does not adequately replace lost volume.
B. 3% sodium chloride (3% NaCl): This solution is hypertonic and has a high sodium concentration. It is not typically used for initial fluid resuscitation in hypovolemia due to severe bleeding. Hypertonic saline solutions like 3% NaCl are more commonly used in specific situations such as severe hyponatremia or cerebral edema.
C. 5% dextrose in water (D5W): This solution contains only dextrose and water and is isotonic until the dextrose is metabolized, after which it becomes hypotonic. D5W is not suitable for fluid resuscitation in hypovolemia due to severe bleeding because it does not provide adequate sodium or volume replacement.

A. continue taking the sedative and discuss slowly decreasing the dose with the physician. B. take the last pill on a Friday so that extra sleep can be obtained on the weekend. C. continue to take the pills since sleeping without them will be very difficult. D. stop taking the medication and take an antihistamine instead.

Correct Answer is A

Explanation

A. Gradual tapering of benzodiazepines under medical supervision is recommended to minimize withdrawal symptoms and rebound insomnia. The client should continue taking the medication as prescribed while discussing a tapering plan with their physician.
B. Abruptly stopping benzodiazepines can lead to withdrawal symptoms, including rebound insomnia, anxiety, agitation, and even seizures. Planning to stop medication on a specific day without medical guidance can increase the risk of withdrawal symptoms occurring during the workweek.

C. While it may be challenging to sleep without benzodiazepines initially, continued use can lead to dependence and tolerance, making it even more challenging to discontinue them in the future. Gradual tapering under medical supervision is the preferred approach.
D. Antihistamines are not typically used as substitutes for benzodiazepines in managing insomnia. Additionally, abruptly stopping benzodiazepines and switching to another medication without medical guidance can lead to withdrawal symptoms and inadequate management of insomnia.

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

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