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 ["0.5"]
Explanation
- The formula is: (Desired dose / Available dose) x Quantity = Number of tablets - In this case: (10 mg / 20 mg) x 1 tablet = 0.5 tablet
- Round the answer to the tenth, or one decimal place, as instructed.
- The final answer is: 0.5 tablet
Correct Answer is C
Explanation
A) Teaching the client to treat symptoms is not sufficient; proactive monitoring is essential.
B) Continuing the drug despite signs of toxicity is not safe and may worsen the client's condition.
C) Regular monitoring of organ function is crucial to detect early signs of toxicity and prevent serious complications.
D) Discontinuing the drug without signs of toxicity may not be necessary, and the decision should be based on ongoing assessment and consultation with the healthcare provider.
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