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 ["A","B"]
Explanation
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
Correct Answer is C
Explanation
C. Dehydration is a state of insufficient fluid intake or excessive fluid loss, leading to electrolyte imbalances and increased concentrations of solutes in the blood. The elevated sodium level (hypernatremia) and slightly elevated glucose level in the context of dehydration are consistent with the laboratory findings. Dehydration can also cause elevated BUN due to decreased kidney perfusion and impaired renal function secondary to hypovolemia. Therefore, dehydration is the most likely condition based on the laboratory findings.
A. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia (low sodium levels). In this case, the sodium level is elevated, which is not consistent with SIADH. Therefore, SIADH is unlikely.
B. Low-protein diet is not typically associated with the laboratory findings presented. Low protein intake would not directly cause elevated sodium, potassium, glucose, or BUN levels. Therefore, this option is unlikely.
D. Renal failure is characterized by impaired kidney function, resulting in electrolyte imbalances, elevated BUN, and abnormal creatinine levels. However, the creatinine level in this case is within the normal range, suggesting preserved kidney function. Additionally, the elevated sodium level is not typically associated with renal failure. Therefore, renal failure is less likely.
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