The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

flush the catheter with normal saline prior to and after medications.

secure the IV catheter to the extremity.

assess IV site frequently throughout the shift.

prevent contamination during the catheter insertion.

Answer and Explanation

The Correct Answer is C

C. Regular assessment of the IV site is crucial to detect early signs of infiltration. Signs of infiltration include swelling, coolness, pain, or blanching around the insertion site. Assessing the site allows nurses to intervene promptly if infiltration occurs, preventing further complications such as tissue damage or fluid overload.

A. Flushing the IV catheter with normal saline helps to maintain patency and prevent blockage of the catheter. It also ensures that medications are effectively delivered into the bloodstream. While this action is important for maintaining the function of the IV catheter, it primarily addresses patency rather than preventing infiltration directly.

B. Securing the IV catheter to the extremity with a securement device (such as tape or a transparent dressing) helps prevent accidental dislodgement or movement of the catheter. This reduces the risk of

mechanical irritation at the insertion site, which can contribute to infiltration. Proper securement also ensures that the catheter remains in place during movement or patient activities.

D. Proper technique during catheter insertion helps reduce the risk of infection and subsequent complications, but it also indirectly contributes to preventing infiltration. Contamination during insertion can lead to inflammation or infection at the site, which may increase the risk of infiltration due to compromised tissue integrity.

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Correct Answer is D

Explanation

D. These effects are not the primary intended outcomes of the medication, but are known possible reactions that can occur in addition to the main therapeutic effect.

A. Synergistic effects refer to the combined action of two or more substances or medications that results in an effect greater than the sum of their individual effects.

B. Adverse effects are unintended and potentially harmful effects of a medication, even when the medication is used at therapeutic doses and in the correct manner.

C. Therapeutic effects are the desired and beneficial effects of a medication that contribute to treating or managing a medical condition. These effects are intended and typically guide the prescribing and administration of medications.

A. "Please, don't be so angry. Things will get better." B. "Maybe I can help. Tell me more about how you're feeling." C. "I'm so sorry that you feel that way." D. "You shouldn't talk like that."

Correct Answer is B

Explanation

B. This is the best response. It demonstrates empathy, active listening, and a willingness to understand the client's emotions. By inviting the client to express their feelings further, the nurse creates an opportunity for therapeutic communication and can better assess how to support the client emotionally.

A. This response dismisses the client's feelings of anger and sadness and may come across as minimizing their emotions. It does not acknowledge the client's current state of distress or provide validation for their feelings.

C. This response expresses empathy and acknowledges the client's feelings, which is important. However, it may seem somewhat passive and could benefit from further exploration or invitation for the client to elaborate on their feelings.

D. This response is dismissive and judgmental. It may make the client feel invalidated or criticized for expressing their emotions, which can further escalate feelings of anger or distress.

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The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

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Naxlex Comprehensive Predictor Exams

The nurse knows that many medications given to clients have predictable, secondary effects which may be harmful or may be beneficial. The nurse always includes these effects in client teaching.

Correct Answer is D

Explanation

The nurse is caring for a client who lost his family in a fire. Upon entering the room, the client states angrily. "I hate this place. No one can help me." The nurse's best response would be:

Correct Answer is B

Explanation

The nurse realizes that a medication error may have occurred. The nurse's first responsibility is to:

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