A client who is receiving a final dose of intravenous cephalosporin complains of pain and irritation at the infusion site. The nurse observes signs of redness at the intravenous insertion site and along the vein. What is the nurse's action?
Request central venous access.
Continue the infusion while elevating the arm.
Immediately stop the infusion and select an alternate intravenous site.
Apply warm packs to the arm and infuse the medication at a slower rate.
The Correct Answer is C
a) Requesting central venous access is not the first-line response to signs of redness, pain, and irritation at the current infusion site. It's essential to address the immediate issue first.
b) Continuing the infusion while elevating the arm may exacerbate the symptoms and is not an appropriate action when there are signs of localized irritation.
c) Stopping the infusion and selecting an alternate intravenous site is the correct action to prevent further complications and assess the cause of the irritation.
d) Applying warm packs and infusing the medication at a slower rate may not be sufficient to address the observed redness and pain, and an alternate site should be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a) Rising slowly from lying to sitting and standing is a precaution to prevent orthostatic hypotension, a potential side effect of calcium channel blockers.
b) Elevating legs if edema occurs is a reasonable response to manage peripheral edema associated with calcium channel blockers.
c) Grapefruit juice can interact with calcium channel blockers, leading to increased drug levels and potential toxicity. This statement indicates a need for additional teaching.
d) Increasing fluid and fiber to limit the risk of constipation is a reasonable measure associated with the use of calcium channel blockers.
Correct Answer is A
Explanation
a) St. John's Wort is known to increase the risk of bleeding, particularly when used in conjunction with anticoagulant medications. This effect is of concern and may require adjustments in the treatment plan.
b) While St. John's Wort can interact with various drugs, increasing the risk of bleeding is a more immediate concern.
c) St. John's Wort does not counteract the effects of CNS depressants; it may actually enhance the effects of these drugs.
d) St. John's Wort is known to induce the metabolism of some drugs, potentially reducing their effectiveness, but the immediate concern is the risk of bleeding.
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