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","C","D","E"]
Explanation
A. The health status prior to the accident can influence how individuals respond to stress. Clients with pre-existing medical conditions, chronic pain, or disabilities may experience increased stress due to concerns about exacerbation of their conditions, recovery, or long-term consequences. Therefore, health status prior to the accident can impact the degree of stress experienced.
B. Age can influence individuals' coping mechanisms and resilience in response to stress. Younger individuals may have less life experience and coping skills, while older individuals may have accumulated more experience and developed better coping strategies over time. Additionally, age-related factors such as physical resilience and social support networks can affect how individuals respond to stressors. Therefore, different ages can influence the degree of stress experienced.
C. External resources such as social support networks, access to healthcare, financial stability, and community resources can significantly impact individuals' ability to cope with stress. Clients with strong support systems, adequate access to medical care, and financial security may experience lower levels of stress compared to those lacking these resources. Therefore, external resources can influence the degree of stress experienced.
D. Individual problem-solving skills play a crucial role in how individuals perceive and manage stressful situations. Clients with strong problem-solving skills may feel more confident in their ability to address challenges and may experience lower levels of stress. Conversely, clients with limited problem-solving skills may feel overwhelmed and experience higher levels of stress. Therefore, individual problem- solving skills can influence the degree of stress experienced.
E. Personality traits such as resilience, optimism, neuroticism, and coping styles can impact how individuals respond to stressors. For example, individuals with resilient personalities and positive coping styles may adapt more effectively to stressors and experience lower levels of stress. Conversely, individuals with neurotic personalities or maladaptive coping styles may be more prone to experiencing heightened stress levels. Therefore, personalities can influence the degree of stress experienced.
Correct Answer is A
Explanation
A. In respiratory alkalosis, the pH is elevated (alkalotic), the PaCO2 (partial pressure of carbon dioxide) is decreased (hypocapnia), and the HCO3 (bicarbonate) level may be within normal limits or slightly decreased due to compensatory mechanisms. In this option, the pH is elevated (7.54), the PaCO2 is decreased (25), and the HCO3 level is within normal limits (24). These findings support respiratory alkalosis.
B. pH 7.50, PaCO2 40, HCO3 28: In this option, the pH is elevated (7.50), the PaCO2 is within normal limits (40), and the HCO3 level is elevated (28). These findings are not consistent with respiratory alkalosis. Instead, they suggest metabolic alkalosis, where both the pH and bicarbonate levels are elevated.
C. pH 7.35, PaCO2 35, HCO3 22: In this option, the pH is within normal limits (7.35), the PaCO2 is within normal limits (35), and the HCO3 level is within normal limits (22). These findings are not consistent with respiratory alkalosis.
D. pH 7.32. PaCO2 48, HCO3 24: In respiratory alkalosis, the pH is elevated (alkalotic), the PaCO2 is decreased (hypocapnia), and the HCO3 level may be within normal limits or slightly decreased due to compensatory mechanisms. In this option, the pH is within normal limits (7.32), the PaCO2 is elevated (48), and the HCO3 level is within normal limits (24). These findings are not consistent with respiratory alkalosis.
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